Partnership Status, Health, and Mortality: Selection or Protection?

Married individuals have better health and lower mortality than nonmarried people. Studies show that when cohabitants are distinguished from other nonmarried groups, health differences between partnered and nonpartnered individuals become even more pronounced. Some researchers have argued that partnered individuals have better health and lower mortality because a partnership offers protective effects (protection); others have posited that partnered people have better health and lower mortality because healthy persons are more likely to form a union and less likely to dissolve it (selection). This study contributes to this debate by investigating health and mortality by partnership status in England and Wales and analyzing the causes of mortality differences. We use combined data from the British Household Panel Survey and the UK Household Longitudinal Study and apply a simultaneous-equations hazard model to control for observed and unobserved selection into partnerships. We develop a novel approach to identify frailty based on self-rated health. Our analysis shows that partnered individuals have significantly lower mortality than nonpartnered people. We observe some selection into and out of unions on unobserved health characteristics, but the mortality differences by partnership status persist. The study offers strong support for the marital protection hypothesis and extends it to nonmarital partnerships.

When does the female bias arise? Insights from the sex determination cascade of a flea beetle with a strongly skewed sex ratio.

Reproduction-manipulating bacteria like Wolbachia can shift sex ratios in insects towards females, but skewed sex ratios may also arise from genetic conflicts. The flea beetle Altica lythri harbors three main mtDNA strains that are coupled to three different Wolbachia infections. Depending on the mtDNA types, the females produce either offspring with a balanced sex ratio or exclusively daughters. To obtain markers that can monitor when sex bias arises in the beetle's ontogeny, we elucidated the sex determination cascade of A. lythri. We established a RT-PCR method based on length variants of dsx (doublesex) transcripts to determine the sex of morphologically indistinguishable eggs and larvae. In females of one mtDNA type (HT1/HT1*) known to produce only daughters, male offspring were already missing at the egg stage while for females of another type (HT2), the dsx splice variants revealed a balanced sex ratio among eggs and larvae. Our data suggest that the sex determination cascade in A. lythri is initiated by maternally transmitted female-specific tra (transformer) mRNA as primary signal. This tra mRNA seems to be involved in a positive feedback loop that maintains the production of the female splice variant, as known for female offspring in Tribolium castaneum. The translation of the maternally transmitted female tra mRNA must be inhibited in male offspring, but the underlying primary genetic signal remains to be identified. We discuss which differences between the mtDNA types can influence sex determination and lead to the skewed sex ratio of HT1.

Do physician networks with standardized audit and feedback deliver better quality care for older patients compared to regular care?: a quasi-experimental study using claims data from Bavaria, Germany.

BACKGROUND: Physician networks (PNs) are a recent development in Germany, designed to improve the coordination and quality of healthcare. We compared the performance of PNs that use a standardized system of audit and feedback to that of regular care. METHODS: We analysed a large sample of claims data from Bavaria, Germany, using nearest-neighbour propensity score matching. Patients who had ambulatory care-sensitive conditions (ACSCs) and were enrolled in PNs were matched with control patients receiving regular care. We examined potentially avoidable hospitalizations related to the 13 most common ACSCs (primary endpoints), as well as processes-of-care indicators for disease prevention, pharmacotherapy and coordination of care. RESULTS: There were no significant differences in rates of potentially avoidable hospitalizations between the two groups. However, the networks showed higher vaccination rates, increased participation in disease management programmes, and more frequent use of referrals when consulting specialist physicians. On average, network patients visited a greater number of specialists and had lower continuity of care compared to patients receiving regular care. Polypharmacy and PRISCUS-list prescriptions were more prevalent in the networks. CONCLUSIONS: PNs using audit and feedback do not appear to perform better than regular care in preventing hospitalizations due to ACSCs. However, they do perform better in disease prevention measures while showing inconclusive results for care coordination and pharmacotherapy. Further research is needed to understand effective collaboration among providers and its impact on the quality of care within PNs.

Regional variation in coronary angiography rates: the association with supply factors and the role of indication: a spatial analysis.

BACKGROUND: Coronary angiographies (CAs) are among the most common diagnostic procedures carried out in German hospitals, and substantial regional differences in their frequency of use have been documented. Given the heterogeneity with regard to the expected benefits and the varying scope for discretion depending on the indication for the procedure, we hypothesized that the observed variation and the association of need and supply factors differs by indication for CA. METHODS: We investigated the correlation between supply factors and the regional rates of CAs in Germany while controlling for need using spatial-autoregressive error models (SARE) and spatial cross-regressive models with autoregressive errors (SCRARE). The overall rates of CAs and the rates in specific patient subgroups, namely, patients with and without myocardial infarction (MI), were calculated based on a comprehensive set of nationwide routine data from three statutory health insurances at the district level. RESULTS: Although little variation was found in cases with MI, considerable variation was seen in the overall cases and cases without MI. The SARE models revealed a positive association between the number of hospitals with a cardiac catheterization laboratory per 10,000 population and the rates of overall cases and cases without MI, whereas no such relationship existed in cases with MI. Additionally, an association between regional deprivation and the rates of CAs was found in cases with MI, but no such association was seen in cases without MI. CONCLUSIONS: The results supported the hypothesis that the relative association of need and supply factors differed by the indication for CA. Although the regional differences in the frequency of use of CAs can only be explained in part by the factors examined in our study, it offers insight into patient access to and the provision of CA services and can provide a platform for further local research.

Special orthopaedic geriatrics (SOG) - a new multiprofessional care model for elderly patients in elective orthopaedic surgery: a study protocol for a prospective randomized controlled trial of a multimodal intervention in frail patients with hip and knee replacement.

BACKGROUND: Due to demographic change, the number of older people in Germany and worldwide will continue to rise in the coming decades. As a result, the number of elderly and frail patients undergoing total hip and knee arthroplasty is projected to increase significantly in the coming years. In order to reduce risk of complications and improve postoperative outcome, it can be beneficial to optimally prepare geriatric patients before orthopaedic surgery and to provide perioperative care by a multiprofessional orthogeriatric team. The aim of this comprehensive interventional study is to assess wether multimorbid patients can benefit from the new care model of special orthopaedic geriatrics (SOG) in elective total hip and knee arthroplasty. METHODS: The SOG study is a registered, monocentric, prospective, randomized controlled trial (RCT) funded by the German Federal Joint Committee (GBA). This parallel group RCT with a total of 310 patients is intended to investigate the specially developed multimodal care model for orthogeriatric patients with total hip and knee arthroplasty (intervention group), which already begins preoperatively, in comparison to the usual orthopaedic care without orthogeriatric co-management (control group). Patients ≥70 years of age with multimorbidity or generally patients ≥80 years of age due to increased vulnerability with indication for elective primary total hip and knee arthroplasty can be included in the study. Exclusion criteria are age < 70 years, previous bony surgery or tumor in the area of the joint to be treated, infection and increased need for care (care level ≥ 4). The primary outcome is mobility measured by the Short Physical Performance Battery (SPPB). Secondary outcomes are morbidity, mortality, postoperative complications, delirium, cognition, mood, frailty, (instrumental) activities of daily living, malnutrition, pain, polypharmacy, and patient reported outcome measures. Tertiary outcomes are length of hospital stay, readmission rate, reoperation rate, transfusion rate, and time to rehabilitation. The study data will be collected preoperative, postoperative day 1 to 7, 4 to 6 weeks and 3 months after surgery. DISCUSSION: Studies have shown that orthogeriatric co-management models in the treatment of hip fractures lead to significantly reduced morbidity and mortality rates. However, there are hardly any data available on the elective orthopaedic care of geriatric patients, especially in total hip and knee arthroplasty. In contrast to the care of trauma patients, optimal preoperative intervention is usually possible. TRIAL REGISTRATION: German Clinical Trials Register DRKS00024102. Registered on 19 January 2021.

Fermi's Golden Rule for Spontaneous Emission in Absorptive and Amplifying Media.

We demonstrate a fundamental breakdown of the photonic spontaneous emission (SE) formula derived from Fermi's golden rule, in absorptive and amplifying media, where one assumes the SE rate scales with the local photon density of states, an approach often used in more complex, semiclassical nanophotonics simulations. Using a rigorous quantization of the macroscopic Maxwell equations in the presence of arbitrary linear media, we derive a corrected Fermi's golden rule and master equation for a quantum two-level system (TLS) that yields a quantum pumping term and a modified decay rate that is net positive. We show rigorous numerical results of the temporal dynamics of the TLS for an example of two coupled microdisk resonators, forming a gain-loss medium, and demonstrate the clear failure of the commonly adopted formulas based solely on the local density of states.

Efficacy and cost-effectiveness of a Transdiagnostic group-based exercise intervention: study protocol for a pragmatic multi-site randomized controlled trial.

BACKGROUND: Mental disorders are prevalent and cause considerable burden of disease. Exercise has been shown to be efficacious to treat major depressive disorders, insomnia, panic disorder with and without agoraphobia and post traumatic stress disorder (PTSD). METHODS: This pragmatic, two arm, multi-site randomised controlled trial will evaluate the efficacy and cost-effectiveness of the manualized, group-based six-months exercise intervention "ImPuls", among physically inactive patients with major depressive disorders, insomnia, panic disorder, agoraphobia and PTSD within a naturalistic outpatient context in Germany. A minimum of 375 eligible outpatients from 10 different study sites will be block-randomized to either ImPuls in addition to treatment as usual (TAU) or TAU only. ImPuls will be conducted by trained exercise therapists and delivered in groups of six patients. The program will combine (a) moderate to vigorous aerobic exercise carried out two-three times a week for at least 30 min with (b) behavior change techniques for sustained exercise behavior change. All outcomes will be assessed pre-treatment, post-treatment (six months after randomization) and at follow-up (12 months after randomization). Primary outcome will be self-reported global symptom severity assessed with the Brief Symptom Inventory (BSI-18). Secondary outcomes will be accelerometry-based moderate to vigorous physical activity, self-reported exercise, disorder-specific symptoms, quality-adjusted life years (QALY) and healthcare costs. Intention-to-treat analyses will be conducted using mixed models. Cost-effectiveness and cost-utility analysis will be conducted using incremental cost-effectiveness and cost-utility ratios. DISCUSSION: Despite its promising therapeutic effects, exercise programs are currently not provided within the outpatient mental health care system in Germany. This trial will inform service providers and policy makers about the efficacy and cost-effectiveness of the group-based exercise intervention ImPuls within a naturalistic outpatient health care setting. Group-based exercise interventions might provide an option to close the treatment gap within outpatient mental health care settings. TRIAL REGISTRATION: The study was registered in the German Clinical Trials Register (ID: DRKS00024152 , 05/02/2021).

Effects of long-term psychodynamic psychotherapy on life quality in mentally disturbed children.

AbstractObjective: Long-term psychodynamic psychotherapy for children aims not only at improving symptoms but also at changing the quality of life. To our knowledge, no studies exist to date that focused on both aspects. In this paper, we investigated changes in problem behavior and health-related quality of life based on long-term psychodynamic psychotherapy with children suffering from emotional and behavioral disorders. Method: We investigated 76 children in the treatment group and analyzed pre- and post-treatment symptoms. Furthermore, we compared the outcome data with a control group of 27 children of similar age and diagnoses who received no psychotherapy, both under routine care conditions. The children included in the study were treated on average for 66 sessions. Parent and adolescent ratings on the Achenbach Scales and the Quality of Life Inventory for Adolescents were compared before and after treatment. Results: We found a highly significant improvement of internalizing symptomatology based on parent ratings with a large effect. Different from prior investigations based on short-term psychodynamic psychotherapy we found changes in quality of life with large effects. Conclusion: These findings indicate that long-term psychodynamic treatment can improve life quality in children beyond symptom change.

Quantization of Quasinormal Modes for Open Cavities and Plasmonic Cavity Quantum Electrodynamics.

We introduce a second quantization scheme based on quasinormal modes, which are the dissipative modes of leaky optical cavities and plasmonic resonators with complex eigenfrequencies. The theory enables the construction of multiplasmon or multiphoton Fock states for arbitrary three-dimensional dissipative resonators and gives a solid understanding to the limits of phenomenological dissipative Jaynes-Cummings models. In the general case, we show how different quasinormal modes interfere through an off-diagonal mode coupling and demonstrate how these results affect cavity-modified spontaneous emission. To illustrate the practical application of the theory, we show examples using a gold nanorod dimer and a hybrid dielectric-metal cavity structure.

Mortality Differences by Partnership Status in England and Wales: The Effect of Living Arrangements or Health Selection?

This article investigates the relationship between partnership status and mortality in England and Wales. Using data from the Office for National Statistics Longitudinal Study for the period between 2001 and 2011, we examine whether married people have lower mortality levels than unmarried individuals; whether individuals who cohabit have mortality levels similar to those of married or single persons; and how much the fact that married couples live with someone rather than alone explains their low mortality. Our analysis shows first that married individuals have lower mortality than unmarried persons. Second, men and women in premarital unions exhibit mortality levels similar to those of married men and women, whereas mortality levels are elevated for post-marital cohabitants. Third, controlling for household size and the presence of children reduces mortality differences between married and unmarried non-partnered individuals, but significant differences persist. The study supports both protection and selection theory. The increase in mortality differences by age between never-married cohabitants and married couples is likely a sign of the long-term accumulation of health and wealth benefits of marriage. Similar mortality levels of cohabiting and married couples at younger ages suggest that healthier individuals are more likely to find a partner.

[Attachment and Externalizing Behavior Problems in Primary School Children with ADHD]. / Bindungsrepräsentation und externalisierende Verhaltensauffälligkeiten von Grundschulkindern mit ADHS.

Attachment and Externalizing Behavior Problems in Primary School Children with ADHD When examining children with ADHD, attachment research does not usually differentiate between the different clinical pictures within the disorder. This study examines attachment and ADHD in children who display a simple or unspecified form of ADHD, in order to be able to draw specific conclusions about this particular group. Attachment, ADHD symptoms as well as externalizing behavior problems were assessed from 93 children aged five to nine years, 48 of whom had an ADHD diagnosis. The distributions of attachment representations between children with ADHD and those without ADHD differ greatly. In addition, externalizing behavior problems differ between attachment classifications. Attachment seems to be an important factor in the etiology of ADHD, however, ADHD as well as externalizing behavior problems as a global construct are too unspecific to determine the influence of attachment on the disorder. Subsequent studies should first focus on specific symptom patterns within the clinical picture whereas clinical practice should consider the parent-child relation an important factor in the development as well as the treatment of ADHD.

Multisite pain, pain frequency and pain severity are associated with depression in older adults: results from the ActiFE Ulm study.

BACKGROUND: there is ample literature showing pain and depression are related. However, different dimensions of pain have been used in former studies. OBJECTIVE: the objective of the study was to compare the strength of the association of different pain dimensions with depression in older adults. METHODS: assessments including evaluation of pain (severity, frequency, chronicity, quality, pain medication, painful body sites) and depression (measured by the Hospital Anxiety and Depression Scale) were performed in an observational study in community dwelling older adults (sample mean age 76, n = 1130) in Germany. The associations of different dimension of pain with depression were assessed using descriptive and multivariate methods. RESULTS: the number of painful body areas was most significantly associated with self-reported late life depression (OR 1.20, CI 1.11-1.31). Pain severity and frequency (OR 1.12, CI 1.01-1.23 and OR 1.18, CI 1.01-1.37) were also associated with depression; quality and duration were not. Except for severity (OR 1.12, CI 1.02-1.24) associations of pain dimensions were strongly reduced when controlling for relevant confounders and gender was an effect modifier. CONCLUSIONS: multisite pain, pain severity and frequency were the best predictors of late life depression. Clinicians should be especially aware of depressive disorders when older patients are complaining of pain in multiple areas across the body.

Exploring heterogeneity in coxarthrosis medication use patterns before total hip replacement: a State Sequence Analysis.

OBJECTIVE: Evidence of geographical variation in total hip replacement (THR) and deviations from treatment guidelines persists. In this exploratory study, we aim to gain an in-depth understanding of patients' healthcare trajectories by identifying and visualising medication use patterns in coxarthrosis patients before surgery. We examine their association with patient characteristics and THR, and compare them with recommendations on mild analgesics, opioid prescription and exhaustion of conservative therapy. METHODS: In this exploratory study, we apply State Sequence Analysis (SSA) on German health insurance data (2012-2015). We analyse a cohort of coxarthrosis patients, half of whom underwent THR after a 1 year observation period and half of whom did not undergo surgery until at least 1 year after the observation period. Hierarchical states are defined based on prescriptions. We construct sequences, calculate sequence similarity using optimal matching and identify medication use patterns via clustering. Patterns are visualised, descriptive statistics are presented and logistic regression is employed to investigate the association of medication patterns with subsequent THR. RESULTS: Seven distinct medication use patterns are identified, correlating strongly with patient characteristics and subsequent THR. Two patterns leading to THR demonstrate exhaustion of pharmacological therapy. Opioid use is concentrated in two small patterns with low odds for THR. The most frequent pattern lacks significant pharmacological therapy. CONCLUSIONS: This SSA uncovers heterogeneity in medication use patterns before surgery in coxarthrosis patients. Cautious opioid handling and adherence to a stepped prescription approach are observed, but many patients display low medication therapy usage and lack evidence of exhausting conservative options before surgery.

Medical App Treatment of Non-Specific Low Back Pain in the 12-month Cluster-Randomized Controlled Trial Rise-uP: Where Clinical Superiority Meets Cost Savings.

Purpose: Non-specific low back pain (NLBP) exerts a profound impact on global health and economics. In the era of Web 3.0, digital therapeutics offer the potential to improve NLBP management. The Rise-uP trial introduces a digitally anchored, general practitioner (GP)-focused back pain management approach with the Kaia back pain app as the key intervention. Here, we present the 12-months evaluation of the Rise-uP trial including clinical and economic outcomes, patient satisfaction and behavioral tracking analysis. Methods: The cluster-randomized controlled study (registration number: DRKS00015048) enrolled 1237 patients, with 930 receiving treatment according to the Rise-uP approach and 307 subjected to standard of care treatment. Assessments of pain, psychological state, functional capacity, and well-being (patient-reported outcome measures; PROMs) were collected at baseline, and at 3-, 6-, and 12-months follow-up intervals. Health insurance partners AOK, DAK, and BARMER provided individual healthcare cost data. An artificial intelligence (AI)-driven behavioral tracking analysis identified distinct app usage clusters that presented all with about the same clinical outcome. Patient satisfaction (patient-reported experience measures; PREMs) was captured at the end of the trial. Results: Intention-to-treat (ITT) analysis demonstrated that the Rise-uP group experienced significantly greater pain reduction at 12 months compared to the control group (IG: -46% vs CG: -24%; p < 0.001) with only the Rise-uP group achieving a pain reduction that was clinically meaningful. Improvements in all other PROMs were notably superior in patients of the Rise-uP group. The AI analysis of app usage discerned four usage clusters. Short- to long-term usage, all produced about the same level of pain reduction. Cost-effectiveness analysis indicated a substantial economic benefit for Rise-uP. Conclusion: The Rise-uP approach with a medical multimodal back pain app as the central element of digital treatment demonstrates both, clinical and economic superiority compared to standard of care in the management of NLBP.

Uranium(III) complexes with bulky aryloxide ligands featuring metal-arene interactions and their reactivity toward nitrous oxide.

We report the synthesis and use of an easy-to-prepare, bulky, and robust aryloxide ligand starting from inexpensive precursor materials. Based on this aryloxide ligand, two reactive, coordinatively unsaturated U(III) complexes were prepared that are masked by a metal-arene interaction via δ-backbonding. Depending on solvent and uranium starting material, both a tetrahydrofuran (THF)-bound and Lewis-base-free U(III) precursor can easily be prepared on the multigram scale. The reaction of these trivalent uranium species with nitrous oxide, N2O, was studied and an X-ray diffraction (XRD) study on single crystals of the product revealed the formation of a five-coordinate U(V) oxo complex with two different molecular geometries, namely, square pyramidal and trigonal bipyramidal.

Concept and study protocol of the process evaluation of a pragmatic randomized controlled trial to promote physical activity in outpatients with heterogeneous mental disorders-the ImPuls study.

BACKGROUND: Evidence suggests that patients suffering from different mental disorders benefit from exercise programs combined with behavior change techniques. Based on this evidence, we have developed an exercise program (ImPuls) specifically designed to provide an additional treatment option in the outpatient mental health care system. The implementation of such complex programs into the outpatient context requires research that goes beyond the evaluation of effectiveness, and includes process evaluation. So far, process evaluation related to exercise interventions has rarely been conducted. As part of a current pragmatic randomized controlled trial evaluating ImPuls treatment effects, we are therefore carrying out comprehensive process evaluation according to the Medical Research Council (MRC) framework. The central aim of our process evaluation is to support the findings of the ongoing randomized controlled trial. METHODS: The process evaluation follows a mixed-methods approach. We collect quantitative data via online-questionnaires from patients, exercise therapists, referring healthcare professionals and managers of outpatient rehabilitative and medical care facilities before, during, and after the intervention. In addition, documentation data as well as data from the ImPuls smartphone application are collected. Quantitative data is complemented by qualitative interviews with exercise therapists as well as a focus-group interview with managers. Treatment fidelity will be assessed through the rating of video-recorded sessions. Quantitative data analysis includes descriptive as well as mediation and moderation analyses. Qualitative data will be analyzed via qualitative content analysis. DISCUSSION: The results of our process evaluation will complement the evaluation of effectiveness and cost-effectiveness and will, for example, provide important information about mechanisms of impact, structural prerequisites, or provider qualification that may support the decision-making process of health policy stakeholders. It might contribute to paving the way for exercise programs like ImPuls to be made successively available for patients with heterogeneous mental disorders in the German outpatient mental health care system. TRIAL REGISTRATION: The parent clinical study was registered in the German Clinical Trials Register (ID: DRKS00024152, registered 05/02/2021, https://drks.de/search/en/trial/DRKS00024152 ).

Reactivity of U-E-U (E = S, Se) toward CO2, CS2, and COS: new mixed-carbonate complexes of the types U-CO2E-U (E = S, Se), U-CS2E-U (E = O, Se), and U-COSSe-U.

We recently reported the formation of a bridging carbonate complex [{(((Ad)ArO)(3)N)U}(2)(µ-η(1):κ(2)-CO(3))] via reductive cleavage of CO(2), yielding a µ-oxo bridged complex, followed by the insertion of another molecule of CO(2). In a similar strategy, we were able to isolate and characterize a series of mixed carbonate complexes U-CO(2)E-U, U-CS(2)E-U, and even U-OC(S)Se-U, by reacting bridged chalcogenide complexes [{(((Ad)ArO)(3)N)U}(2)(µ-E)] (E = S, Se) with CO(2), CS(2), and COS. These chalcogenido mixed-carbonate complexes represent the first of their kind.

Observation of the inverse trans influence (ITI) in a uranium(V) imide coordination complex: an experimental study and theoretical evaluation.

An inverse trans influence has been observed in a high-valent U(V) imide complex, [(((Ad)ArO)(3)N)U(NMes)]. A thorough theoretical evaluation has been employed in order to corroborate the ITI in this unusual complex. Computations on the target complex, [(((Ad)ArO)(3)N)U(NMes)], and the model complexes [(((Me)ArO)(3)N)U(NMes)] and [(NMe(3))(OMe(2))(OMe)(3)U(NPh)] are discussed along with synthetic details and supporting spectroscopic data. Additionally, the syntheses and full characterization data of the related U(V) trimethylsilylimide complex [(((Ad)ArO)(3)N)U(NTMS)] and U(IV) azide complex [(((Ad)ArO)(3)N)U(N(3))] are also presented for comparison.

Physical performance and daily walking duration: associations in 1271 women and men aged 65-90 years.

BACKGROUND AND AIMS: Several tests of physical performance like gait speed or standing balance are part of the geriatric assessment. Measures of physical activity like daily walking duration are more difficult to assess but may be of higher relevance for daily requirements. It is therefore of interest to what extent physical performance measures are associated with physical activity. METHODS: In a cohort study, baseline screening was performed in 1271 community-living people aged 65-90 years from Ulm, Germany. Average daily walking duration was assessed in all participants by accelerometers over a one-week period. Habitual gait speed, 5-Chair-Rise test, standing balance and handgrip strength served as measures of physical performance. The association between measures of physical performance and physical activity was calculated by linear regression analysis. RESULTS: The mean daily walking duration was 104.8 minutes in men and 103.0 minutes in women. A positive relationship between gait speed and walking duration was observed in men and women with low gait speed (≤0.8 m/s) but not in participants above this threshold. Standing balance and hand grip strength were positively and 5-Chair-Rise test inversely related with average daily walking duration. A relationship between hand grip strength and walking duration was only observed in women aged 75 years and more. CONCLUSIONS: Physical performance measures and objectively measured walking duration are related with each other but only a small percentage of the variance of daily walking duration was explained by physical performance measures. Therefore, factors other than physical performance seem to influence daily walking duration to a great extent.

Attachment Representation and Emotion Recognition Ability in Children with ADHD and Their Parents: A Study Protocol.

Background: Few studies in clinical attachment research to date have examined children with an attention-deficit/hyperactivity disorder (ADHD) diagnosis. This is surprising for two reasons: first, there are a number of parallels between the behaviors of children with an insecure and disorganized attachment and the behaviors of children with an ADHD diagnosis. Second, secure attachment has a positive effect on the development of skills in areas in which children with ADHD demonstrate problems (e.g., attention span, impulse control). There are currently no findings on whether or not and how insecure and disorganized attachment and ADHD affect children's emotion recognition ability. Methods: This is a cross-sectional study, part exploratory and part hypothesis-driven in the context of basic research. A clinical sample of 5- to 10-year-old children with an ADHD diagnosis and their parents is to be compared to a non-clinical unaffected control group. Over a period of 3 years, 80 subjects and their parents are to be recruited in each group for participation in the study. Discussion: This study is the first to examine links between attachment, emotion recognition ability, and ADHD. It is also the first to include not just children with ADHD but also their mothers and fathers in its design. The findings should help reduce the research gap and generate more knowledge for family interventions in the case of ADHD.