Factors associated with family caregiver burden among frail older persons with multimorbidity.

INTRODUCTION: Singapore is facing an ageing population and the care needs of the population will increase in tandem. A segment of this population would be living with multimorbidity and frailty. Frailty is defined as an age-related state characterised by reduced strength and physiologic malfunctioning. Multimorbidity refers to the coexistence of multiple chronic conditions in an individual. Older adults are more likely to have frailty and multimorbidity, and this would increase the burden of their caregiver. Our study aimed to determine the prevalence of caregiver burden for primary family caregivers of frail older adults with multimorbidity. We also investigated the factors that were associated with primary family caregiver burden. METHODS: This was an interviewer-administered, cross-sectional study of primary family caregivers of frail older patients with multimorbidity that was conducted in two National Healthcare Group polyclinics. Convenience sampling was used. The 12-item Zarit Burden Index (ZBI) was used to assess primary family caregiver burden. The scores of the ZBI range from 0 to 48, with a score of 10 or above indicating that the primary family caregiver perceives burden. Descriptive statistics were used to provide information regarding the caregivers and the care recipients. Multivariable logistic regression was used to investigate the factors affecting primary family caregiver burden. RESULTS: One hundred eighty-eight family caregivers were interviewed and 71.8% of them perceived burden on the ZBI. 59.6% were caregivers to their parents and 18.1% of them had multimorbidity. Almost two-thirds of the caregivers interviewed were female. After adjusting for other factors via multivariable analysis, the ethnicity of the caregiver and the increase in time spent caregiving per week were the two factors positively associated with family caregiver burden. A Chinese primary family caregiver had almost three times the odds of perceiving burden when compared to a non-Chinese primary family caregiver. CONCLUSION: Caregiver burden was high amongst primary family caregivers of frail older adults with multimorbidity. Being a Chinese primary family caregiver compared to non-Chinese ethnic groups as well as being a primary family caregiver who spent increased time caregiving per week were the two factors positively associated with family caregiver burden. Further exploratory, qualitative studies can be done to find out the reasons to Chinese primary family caregivers being more burdened compared to the non-Chinese primary family caregivers. In addition, the specific factors related to increased time caregiving per week and family caregiver burden can also be studied.

How does multimorbidity affect middle-aged adults? A cross-sectional survey in the Singapore primary healthcare setting.

BACKGROUND: Multimorbidity is of increasing prevalence and importance. It has been associated with poorer health-related quality of life (HrQoL) especially in the elderly population. Despite substantial multimorbidity in the middle-aged population, defined as those aged between 40-64 years old, there is a paucity of research investigating the impact of multimorbidity in this population. This study aimed to investigate the association between multimorbidity and HrQoL in the middle-aged primary care population in Singapore. METHODS: A cross-sectional study was conducted at a primary care centre in Singapore. Interviewer-administered questionnaires were used to collect data regarding the participants' sociodemographic characteristics, chronic conditions, and HrQoL, as measured by the EuroQol five dimensions 3-levels questionnaire (EQ5D). We defined multimorbidity as the presence of three or more conditions, out of a list of 14 chronic conditions. The associations between multimorbidity and the components of the EQ5D were assessed using multivariable regression analyses. RESULTS: The study included 297 participants, aged 40-64 years, of which 124 (41.7%) had multimorbidity. After adjusting for sociodemographic factors, participants with multimorbidity had significantly lower EQ5D UI, (ß-coefficient - 0.064 (C.I -0.125, - 0.003), p = 0.04), but not significantly lower EQ5D VAS, (ß-coefficient - 0.045 (C.I 0.102, 0.012), p = 0.12). Additionally, participants with multimorbidity had higher odds (OR = 2.41, p = 0.01) of reporting problems due to pain/discomfort. CONCLUSION: Multimorbidity was not significantly associated with the overall health state, as measured by the EQ5D VAS, in middle-aged primary care patients. However, it was associated with the EQ5D UI which is a composite measure of five specific domains of HrQoL. Specifically, there was a statistically significant association between multimorbidity and the pain domain. Further studies are required to understand the relationship between multimorbidity and pain to enable physicians to better manage pain and HrQoL in this population.

Comfort and Ground Reaction Forces in Flat-Footed Female Runners: Comparison of Low-Dye Taping versus Sham Taping.

The purpose of this study was to examine the effects of low-Dye tape on comfort and ground reaction forces (GRF) in flat-footed female runners. A randomized cross-over study was conducted on 15 flat-footed female recreational runners. Participants ran at three speeds (9, 10, 11 km/h) under two conditions: low-Dye and sham taping. Comfort level was assessed using a 150-mm visual analog scale. GRF data were collected using an instrumented treadmill. Stance time, peak forces, and loading rates were extracted. Low-Dye taping showed a lower comfort level (low-Dye, 63.8 (24.3) mm, sham 122.0 (16.0) mm, mean difference [95% confident intervals], -58.2 [68.2, 48.2] mm, p < 0.001). For all biomechanical variables, there was no interaction (taping condition a speed) effect or difference between taping conditions. As running speed increased, there was a decrease in stance time (p < 0.001) and increase in loading rate (p = 0.009), impact peak (p = 0.004), active peak (p < .001), breaking peak (p < 0.001), propulsive peak (p < 0.001), medial peak (p < 0.001), and lateral peak (p < 0.001). Compared with sham taping, application of low-Dye taping was less comfortable but did not alter running ground reaction forces among flat-footed female runners.

Carrying the past to the future: Distinct brain networks underlie individual differences in human spatial working memory capacity.

Spatial working memory (SWM) relies on the interplay of anatomically separated and interconnected large-scale brain networks. EEG studies often observe load-associated sustained negative activity during SWM retention. Yet, whether and how such sustained negative activity in retention relates to network-specific functional activation/deactivation and relates to individual differences in SWM capacity remain to be elucidated. To cover these gaps, we recorded concurrent EEG-fMRI data in 70 healthy young adults during the Sternberg delayed-match-to-sample SWM task with three memory load levels. To a subset of participants (N = 28) that performed the task properly and had artefact-free fMRI and EEG data, we employed a novel temporo-spatial principal component analysis to derive load-dependent negative slow wave (NSW) from retention-related event-related potentials. The associations between NSW responses with SWM capacity were divergent in the higher (N = 14) and lower (N = 14) SWM capacity groups. Specifically, larger load-related increase in NSW amplitude was associated with greater SWM capacity for the higher capacity group but lower SWM capacity for the lower capacity group. Furthermore, for the higher capacity group, larger NSW amplitude was related to greater activation in bilateral parietal areas of the fronto-parietal network (FPN) and greater deactivation in medial frontal gyrus and posterior mid-cingulate cortex of the default mode network (DMN) during retention. In contrast, the lower capacity group did not show similar pattern. Instead, greater NSW was linked to higher deactivation in right posterior middle temporal gyrus. Our findings shed light on the possible differential EEG-informed neural network mechanism during memory maintenance underlying individual differences in SWM capacity.

Concordance of self-reporting of diabetes compared with medical records: A comparative study using polyclinic data in Singapore.

INTRODUCTION: Studies of concordance between patients' self-report of diseases and a criterion standard (e.g. chart review) are usually conducted in epidemiological studies to evaluate the agreement of self-reported data for use in public health research. To our knowledge, there are no published studies on concordance for highly prevalent chronic diseases such as diabetes and pre-diabetes. The aims of this study were to evaluate the concordance between patients' self-report and their medical records of diabetes and pre-diabetes diagnoses, and to identify factors associated with diabetes concordance. METHOD: A cross-sectional, interviewer-administered survey was conducted on patients with chronic diseases after obtaining written consent to assess their medical notes. Interviewers were blinded to the participants' profiles. Concordance was evaluated using Cohen's kappa (κ). A multivariable logistic regression model was used to identify factors associated with diabetes concordance. RESULTS: There was substantial agreement between self-reported and medical records of diabetes diagnoses (κ=0.76) and fair agreement for pre-diabetes diagnoses (κ=0.36). The logistic regression model suggested that non-Chinese patients had higher odds of diabetes concordance than Chinese patients (odds ratio [OR]=4.10, 95% confidence interval [CI] 1.19-14.13, P=0.03). Patients with 3 or more chronic diseases (i.e. multimorbidity) had lower odds of diabetes concordance than patients without multimorbidity (OR=0.21, 95% CI 0.09-0.48, P<0.001). CONCLUSION: Diabetes concordance was substantial, supporting the use of self-report of diabetes by patients with chronic diseases in the primary care setting for future research. Pre-diabetes concordance was fair and may have important clinical implications. Further studies to explore and improve health literacy and patient-physician communication are needed.

Psychosocial factors and caregiver burden among primary family caregivers of frail older adults with multimorbidity.

BACKGROUND: Provision of care for frail older adults with multiple chronic diseases (multimorbidity) poses increasing challenge for family caregivers. Our study aims to evaluate to what extent caregiving competence, social support and positive aspects of caregiving can mitigate the effect of burden experienced by family caregivers of frail older adults with multimorbidity. METHODS: A descriptive cross-sectional study was conducted in 2 primary care clinics. Family caregivers of older adults aged 65 years and above were invited to complete interviewer-administered questionnaires. Descriptive statistics were used to describe sociodemographic and clinical data. Caregiver's burden was measured using the Zarit Burden Interview (ZBI). Mann-Whitney U test was used to compare differences in Caregiving Competence Scale (CCS), short Positive Aspects of Caregiving (S-PAC) and modified Medical Outcome Study Social support (mMOS-SS). Multivariable logistic regression was used to analyse factors associating with caregiver burden. RESULTS: A total of 188 participants were recruited. 71.8% reported caregiver burden (ZBI score ≥ 10). Caregivers who perceived burden had significantly lower CCS, S-PAC and mMOS-SS scores than those who did not (10.0 vs 11.6; 26.8 vs 29.8; 24.8 vs 31.4, p < 0.001 respectively). Factors significantly associated with higher odds of perceived burden were presence of alternative caregivers (OR 3.3, 95% CI 1.09, 10.19, p = 0.04), use of community resources (OR 4.4, 95% CI 1.15, 16.83, p = 0.03) and time spent caregiving per week (OR 1.1, 95% CI 1.02, 1.10, p = 0.003). DISCUSSION AND CONCLUSION: This study found that caregivers had high perception of burden as demand in caregiving may increase. Anticipating caregiver burden and social support needs may be important part of managing these frail older adults.

How do older adults with multimorbidity navigate healthcare?: a qualitative study in Singapore.

BACKGROUND: Patients living with multimorbidity may require frequent visits to multiple healthcare institutions and to follow diverse medical regimens and advice. Older adults with multimorbidity could face additional challenges because of declining cognitive capability, frailty, increased complexity of diseases, as well as limited social and economic resources. Research on how this population navigates the healthcare system in Singapore also remains unknown. This study investigates the challenges older adults with multimorbidity face in navigating healthcare in Singapore. METHODS: Twenty older adults with multimorbidity from a public primary care setting were purposively sampled. Interviews conducted inquired into their experiences of navigating the healthcare system with multiple conditions. Inductive thematic analysis was performed by independent coders who resolved differences through discussion. RESULTS: Older adults with multimorbidity form a population with specific characteristics and challenges. Their ability to navigate the healthcare system well was influenced by these themes including patient-related factors (autonomy and physical mobility, literacy and technological literacy, social support network), healthcare system-related factors (communication and personal rapport, fragmented system, healthcare staff as advocate) and strategies for navigation (fitting in, asking for help, negotiating to achieve goals, managing the logistics of multimorbidity). DISCUSSION: Older adults with multimorbidity should not be treated as a homogenous group but can be stratified according to those with less serious or disruptive conditions (less burden of illness and burden of treatment) and those with more severe conditions (more burden of illness and burden of treatment). Among the latter, some became navigational experts while others struggled to obtain the resources needed. The variations of navigational experiences of the healthcare system show the need for further study of the differential needs of older adults with multimorbidity. To be truly patient-centred, healthcare providers should consider factors such as the existence of family support networks, literacy, technological literacy and the age-related challenges older adults face as they interact with the healthcare system, as well as finding ways to improve healthcare systems through personal rapport and strategies for reducing unnecessary burden of treatment for patients with multimorbidity.

Perceived stress and associated factors among healthcare workers in a primary healthcare setting: the Psychological Readiness and Occupational Training Enhancement during COVID-19 Time (PROTECT) study.

INTRODUCTION: Disease outbreaks such as the COVID-19 pandemic significantly heighten the psychological stress of healthcare workers (HCWs). The objective of this study was to understand the factors contributing to the perceived stress levels of HCWs in a public primary care setting during the COVID-19 pandemic, including their training, protection and support (TPS), job stress (JS), and perceived stigma and interpersonal avoidance. METHODS: This cross-sectional study using an electronic self-administered questionnaire was conducted at the National Healthcare Group Polyclinics in March 2020. Data was collected anonymously. Analysis was performed using regression modelling. RESULTS: The response rate was 69.7% (n = 1,040). The mean perceived stress level of HCWs in various departments ranged from 17.2 to 20.3. Respondents who reported higher perceived stress were those who made alternative living arrangements, were more affected by the current pandemic, reported higher JS and were Muslims. Respondents who reported lower perceived stress were those who had been through the severe acute respiratory syndrome epidemic in 2003 and H1N1 pandemic in 2009 as HCWs, and those who had higher confidence in the organisation's TPS. CONCLUSION: All HCWs, regardless of their scope of work, were similarly stressed by the current pandemic compared to the general population. Improving the confidence of HCWs in their training, protection and the support of personal protective equipment, and retaining experienced HCWs who can provide advice and emotional support to younger colleagues are important. Adequate psychological support for HCWs in the pandemic can be transformed into reserves of psychological resilience for future disease outbreaks.

Healthcare cost of patients with multiple chronic diseases in Singapore public primary care setting.

INTRODUCTION: The rising prevalence of multiple chronic diseases is an important public health issue as it is associated with increased healthcare utilisation. This paper aimed to explore the annual per capita healthcare cost in primary care for patients with multiple chronic diseases (multimorbidity). METHODS: This was a retrospective cohort study conducted in a cluster of public primary care clinics in Singapore. De-identified data from electronic medical records were extracted from July 2015 to June 2017. Only patients with at least 1 chronic disease were included in the study. Basic demographic data and healthcare cost were extracted. A list of 20 chronic diseases was considered for multimorbidity. RESULTS: There were 254,377 patients in our study population, of whom 52.8% were female. The prevalence of multimorbidity was 62.4%. The median annual healthcare cost per capita for patients with multimorbidity was about twice the amount compared to those without multimorbidity (SGD683 versus SGD344). The greatest percentage increment in cost was when the number of chronic diseases increased from 2 to 3 (43.0%). CONCLUSION: Multimorbidity is associated with higher healthcare cost in primary care. Since evidence for the optimal management of multimorbidity is still elusive, prevention or delay in the onset of multimorbidity in the general population is paramount.

Systematic review on the instruments used for measuring the association of the level of multimorbidity and clinically important outcomes.

OBJECTIVES: There are multiple instruments for measuring multimorbidity. The main objective of this systematic review was to provide a list of instruments that are suitable for use in studies aiming to measure the association of a specific outcome with different levels of multimorbidity as the main independent variable in community-dwelling individuals. The secondary objective was to provide details of the requirements, strengths and limitations of these instruments, and the chosen outcomes. METHODS: We conducted the review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO registration number: CRD42018105297). We searched MEDLINE, Embase and CINAHL electronic databases published in English and manually searched the Journal of Comorbidity between 1 January 2010 and 23 October 2020 inclusive. Studies also had to select adult patients from primary care or general population and had at least one specified outcome variable. Two authors screened the titles, abstracts and full texts independently. Disagreements were resolved with a third author. The modified Newcastle-Ottawa Scale was used for quality assessment. RESULTS: Ninety-six studies were identified, with 69 of them rated to have a low risk of bias. In total, 33 unique instruments were described. Disease Count and weighted indices like Charlson Comorbidity Index were commonly used. Other approaches included pharmaceutical-based instruments. Disease Count was the common instrument used for measuring all three essential core outcomes of multimorbidity research: mortality, mental health and quality of life. There was a rise in the development of novel weighted indices by using prognostic models. The data obtained for measuring multimorbidity were from sources including medical records, patient self-reports and large administrative databases. CONCLUSIONS: We listed the details of 33 instruments for measuring the level of multimorbidity as a resource for investigators interested in the measurement of multimorbidity for its association with or prediction of a specific outcome.

Video Consultations for Older Adults With Multimorbidity During the COVID-19 Pandemic: Protocol for an Exploratory Qualitative Study.

BACKGROUND: Multimorbidity, the coexistence of multiple chronic conditions in an individual, is a growing public health challenge. Amidst the COVID-19 pandemic, physical distancing remains an indispensable measure to limit the spread of the virus. This pertains especially to those belonging to high-risk groups, namely older adults with multimorbidity. In-person visits are discouraged for this cohort; hence, there is a need for an alternative form of consultation such as video consultations to continue the provision of care. OBJECTIVE: The potential of video consultations has been explored in several studies. However, the emergence of COVID-19 presents us with an unprecedented opportunity to explore the use of this technological innovation in a time when physical distancing is imperative. This study will evaluate the sustainability of video consultations on a micro-, meso-, and macro-level by assessing the views of patients, physicians, and organizational and national policymakers, respectively. METHODS: The NASSS (nonadoption, abandonment, scale-up, spread, and sustainability) framework was designed as a guide for the development of health care technologies. In this study, the implementation of and experiences related to video consultations will be studied using the NASSS framework. Individual in-depth interviews or focus group discussions will be conducted with participants using the Zoom platform. Data will be analyzed by at least two investigators trained in qualitative methodology, organized thematically, and coded in two phases-an initial phase and a focused selective phase. All disagreements will be resolved by consulting the larger research team until consensus is reached. RESULTS: This study was approved for funding from the Geriatric Education and Research Institute. Ethics approval was obtained from the National Healthcare Group Domain Specific Review Board (reference #2020/00760). Study recruitment commenced in July 2020. The results of the data analysis are expected to be available by the end of the year. CONCLUSIONS: This study aims to evaluate the adoption and sustainability of video consultations for older adults with multimorbidity during the pandemic as well as post COVID-19. The study will yield knowledge that will challenge the current paradigm on how care is being delivered for community-dwelling older adults with multimorbidity. Findings will be shared with administrators in the health care sector in order to enhance the safety and quality of these video consultations to improve patient care for this group of population. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/22679.

Experiences of older primary care patients with multimorbidity and their caregivers in navigating the healthcare system: A qualitative study protocol.

BACKGROUND: Patients with multimorbidity must bear not just the burden of their illness, but also the burden of treatment which is, in part, induced by their interactions with the healthcare system. The need to shuttle between different healthcare institutions and multiple healthcare providers can make navigating the healthcare system challenging, and this may be even more so for older patients with limited resources and support. OBJECTIVES: Few qualitative studies have explored the experiences of patients with multimorbidity in navigating the healthcare system. This study will explore the experiences of older patients with multimorbidity and their caregivers as they navigate through the healthcare system. We aim to arrive at a better understanding of patient experiences of possible gaps in the continuity of care and how the current system can be modified and adapted to better address the needs of older patients with multimorbidity. METHOD: Semi-structured, in-depth interviews will be conducted with purposively sampled older patients with multimorbidity, aged 60 and above seen in primary care, together with their caregivers. Interviews will be transcribed verbatim and analysed by the study team using inductive thematic analysis. CONCLUSIONS: Our study seeks to explore the navigational experiences within the healthcare system for older patients with multimorbidity in an Asian, multi-ethnic society. The findings will be shared with decision-makers in the healthcare setting in order to improve patient care for this population and ultimately maximise their positive health outcomes, and will add to better understanding how the burden of treatment arising from navigational challenges within the healthcare system may be reduced for older patients with multimorbidity.

Large-scale brain functional network topology disruptions underlie symptom heterogeneity in children with attention-deficit/hyperactivity disorder.

Accumulating evidence suggests brain network dysfunction in attention-deficit/hyperactivity disorder (ADHD). Whether large-scale brain network connectivity patterns reflect clinical heterogeneity in ADHD remains to be fully understood. This study aimed to characterize the differential within- and between-network functional connectivity (FC) changes in children with ADHD combined (ADHD-C) or inattentive (ADHD-I) subtypes and their associations with ADHD symptoms. We studied the task-free functional magnetic resonance imaging (fMRI) data of 58 boys with ADHD and 28 demographically matched healthy controls. We measured within- and between-network connectivity of both low-level (sensorimotor) and high-level (cognitive) large-scale intrinsic connectivity networks and network modularity. We found that children with ADHD-C but not those with ADHD-I exhibited hyper-connectivity within the anterior default mode network (DMN) compared with controls. Additionally, children with ADHD-C had higher inter-network FC between the left executive control (ECN) and the salience (SN) networks, between subcortical and visual networks, and between the DMN and left auditory networks than controls, while children with ADHD-I did not show differences compared with controls. Similarly, children with ADHD-C but not ADHD-I showed lower network modularity compared with controls. Importantly, these observed abnormal inter-network connectivity and network modularity metrics were associated with Child Behavioral Checklist (CBCL) attention-deficit/hyperactivity problems and internalizing problems in children with ADHD. This study revealed relatively greater loss of brain functional network segregation in childhood ADHD combined subtype compared to the inattentive subtype, suggesting differential large-scale functional brain network topology phenotype underlying childhood ADHD heterogeneity.

Brain-computer-interface-based intervention re-normalizes brain functional network topology in children with attention deficit/hyperactivity disorder.

A brain-computer-interface (BCI)-based attention training game system has shown promise for treating attention deficit/hyperactivity disorder (ADHD) children with inattentive symptoms. However, little is known about brain network organizational changes underlying behavior improvement following BCI-based training. To cover this gap, we aimed to examine the topological alterations of large-scale brain functional networks induced by the 8-week BCI-based attention intervention in ADHD boys using resting-state functional magnetic resonance imaging method. Compared to the non-intervention (ADHD-NI) group, the intervention group (ADHD-I) showed greater reduction of inattention symptoms accompanied with differential brain network reorganizations after training. Specifically, the ADHD-NI group had increased functional connectivity (FC) within the salience/ventral attention network (SVN) and increased FC between task-positive networks (including the SVN, dorsal attention (DAN), somatomotor, and executive control network) and subcortical regions; in contrast ADHD-I group did not have this pattern. In parallel, ADHD-I group had reduced degree centrality and clustering coefficient as well as increased closeness in task-positive and the default mode networks (prefrontal regions) after the training. More importantly, these reduced local functional processing mainly in the SVN were associated with less inattentive/internalizing problems after 8-week BCI-based intervention across ADHD patients. Our findings suggest that the BCI-based attention training facilitates behavioral improvement in ADHD children by reorganizing brain functional network from more regular to more random configurations, particularly renormalizing salience network processing. Future long-term longitudinal neuroimaging studies are needed to develop the BCI-based intervention approach to promote brain maturation in ADHD.

Early cerebral volume reductions and their associations with reduced lupus disease activity in patients with newly-diagnosed systemic lupus erythematosus.

We examined if cerebral volume reduction occurs very early during the course of systemic lupus erythematosus (SLE), and observed prospectively whether gray (GMV) and white matter volumes (WMV) of the brain would improve with lowered SLE disease activity. T1-weighted MRI brain images were obtained from 14 healthy controls (HC) and 14 newly-diagnosed SLE patients within 5 months of diagnosis (S1) and after achieving low disease activity (S2). Whole brain voxel-based morphometry was used to detect differences in the GMV and WMV between SLE patients and HC and those between SLE patients at S1 and S2. SLE patients were found to have lower GMV than HC in the middle cingulate cortex, middle frontal gyrus and right supplementary motor area, and lower WMV in the superior longitudinal fasciculus, cingulum cingulate gyrus and inferior fronto-occipital fasciculus at both S1 and S2. Whole-brain voxel-wise analysis revealed increased GMV chiefly in the prefrontal regions at S2 compared to S1 in SLE patients. The GMV increase in the left superior frontal gyrus was significantly associated with lowered SLE disease activity. In conclusion, GMV and WMV reduced very early in SLE patients. Reduction of SLE disease activity was accompanied by region-specific GMV improvement in the prefrontal regions.

Intrinsic Affective Network Is Impaired in Children with Attention-Deficit/Hyperactivity Disorder.

Deficits in impulsivity and affect dysregulation are key features of attention-deficit/hyperactivity disorder (ADHD) besides impairing levels of hyperactivity and/or inattention. However, the neural substrates underlying these traits are relatively under-investigated. In this study, we use resting-state functional magnetic resonance imaging to test the hypothesis of diminished functional integration within the affective/limbic network (which includes the amygdala, hippocampus, subgenual cingulate cortex, orbitofrontal cortex and nucleus accumbens) of children with ADHD, which is associated with their behavioral measures of emotional control deficits. Resting state-fMRI data were obtained from 12 healthy control subjects and 15 children with ADHD, all who had a minimum one-month washout period for medications and supplements. Children with ADHD demonstrated less integrated affective network, evidenced by increased bilateral amygdalar and decreased left orbitofrontal connectivity within the affective network compared to healthy controls. The hyper-connectivity at the left amygdalar within the affective network was associated with increased aggressiveness and conduct problems, as well as decline in functioning in children with ADHD. Similar findings in affective network dysconnectivity were replicated in a subset of children with ADHD three months later. Our findings of divergent changes in amygdala and orbitofrontal intrinsic connectivity support the hypothesis of an impaired functional integration within the affective network in childhood ADHD. Larger prospective studies of the intrinsic affective network in ADHD are required, which may provide further insight on the biological mechanisms of emotional control deficits observed in ADHD.