الفهرس 
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Abstract
ADHD is the most diagnosed mental health condition in children in the United States. Prevalence figures vary among agencies, but the Centers for Disease Control and Prevention estimates that 3% to 7% of school-aged children in the United States have this diagnosis. There has been an increase of 3% each year since 1997 in the number of children diagnosed with ADHD(Visser et al., 2014). The diagnosis of ADHD is clinical, but difficult, because there is no single, simple method of diagnosing the condition. Diagnosis depends on observations from parents, teachers and other careers, the doctor’s clinical judgement, and the use of diagnostic tools as guidelines. Diagnostic difficulties are further compounded by the existence of other psychiatric disorders and medical illnesses that mimic ADHD(Mueller & Tomblin, 2012). This study was carried out in Neuropsychiatry Department, Psychiatry and Neurology Center and Diagnostic Radiology department in Tanta University over a period starting from October 2020 till September 2022. It was performed on 50 participants. they were classified as 30 children and adolescents’ patients with ADHD and 20 normal healthy children and adolescents free from any psychiatric disorders. Aim of the work: In this study fMRI was used to evaluate whether functional brain connectivity is altered in children and adolescents with ADHD and to correlate any detected changes with clinical and demographic data of children and adolescents with ADHD. And we compared fMRI brain changes in children and adolescents with ADHD to children and adolescents without ADHD. Subjects and methods : All subjects were subjected to the following A) Clinical Assessment: The clinical assessment included neurological examination, and general examination. 1-Neurological examination: This involved examination of cranial nerves, motor system coordination, superficial reflexes, deep reflexes, and the sensory system. The neurological examination was performed to exclude cases with neurological illness. All the participants were having no localization. 2-General examination: This involved examination the head and neck, the chest and abdomen. B) Detailed psychiatric Assessment: A detailed psychiatric assessment was done using the following scales: 1- The Stanford-Binet test 5th edition 2-Arabic version of Achenbach Child Behavioral Check List (CBCL) 3- The Arabic version of Kiddie Schedule for Affective Disorders and Schizophrenia 4- Arabic version of Conners’ Rating Scale for ADHD (parents and teacher edition) 5- socioeconomic status scale (El-Gilany, A. et al., 2012). C- Radiological imaging: In all the study participants structural and functional images of the brain were obtained by 1.5-Tesla MR unit (Signa Horizon SR 120; General Electric Medical Systems, Milwaukee, WI, USA) with 8-channel head coil. The data obtained by R-fMRI was analyzed, with motion correction, standard volume-realignment followed by independent component analysis-based automatic removal of motion artifacts, by using the commercially available corresponding software (Functool, HD version 15.0 M4A, GE Healthcare Medical Systems, Milwaukee, WI, USA). To identify the well-established brain networks, the independent components found in the ADHD group were correlated and compared with brain networks, which were identified in age and sex matched healthy participants. Results The study revealed the following: As regards demographic data, non-significant statically differences between patients’ group and control group as regards Age, gender, age group, residence, years of education family socioeconomic status IQ and type of family. As regards ADHD subtypes, another important finding was that the most observed subtype was combined subtype, which constituted 46.67% of the studied sample followed by inattentive subtype which represent 16.67 % and lastly hyperactive/impulsive subtype. As regards gender distribution among ADHD subtypes, this study showed that there was a statistically significant difference between distribution of ADHD subtypes between boys and girls, as boys were more affected with combined and hyperactive subtype while females were more affected by inattentive subtype. As regards severity assessment of ADHD, assessment of severity of ADHD by Conners’ Rating scale (parent and teacher edition) revealed that moderate degree of severity is present in most of children followed by marked degree in parent edition and by mild degree in teacher edition. As regards ADHD Scholastic achievement, the scholastic achievement of the studied children according to CBCL was significantly different between the studied groups. It was found that (43.33%) of the studied children with ADHD had poor scholastic achievement, 13.33%had fair achievement, and (36.67%) had good achievement, where 6.67%left school, while in control group (10%) of the studied children had poor scholastic achievement, 25%had fair achievement, and (65%) had good achievement, where 0% left school, with statistically significant difference. Thus, the presence of ADHD in the studied children significantly affect their academic performance & caused poor scholastic achievement. As regards family type in ADHD children and adolescents, ADHD in studied children were more common among nuclear families (70%) than extended families (30%). As regards ADHD patient’s Relation to parents and siblings, we had found that 53.33%of the studied sample had poor relation to their parents, 30%had fair relation, and only 16.67%had good relation. We had found that 43.33%of the studied sample had poor relation to their siblings, 40%had fair relation, and only 0%had good relation and, 16.67% had no siblings. As regards ADHD patient’s relation to teachers and school mates, regarding school environment & the relation of studied sample to teachers, it was found that 40.74% had fair relation to teachers, one third (33.3%) had poor relation, and 11.11% had good relation, while 14.81% left school. Half of the children had poor relation to school mates, 24.07% had fair relation and 25.92% had good relation. As regards ADHD patient’s and competence parameters of CBCL, according to CBCL, most of ADHD children had low competence parameters. There was a statistically significant difference (P value < 0.001) on the type of ADHD and social competence in the studied children, where the lowest parameters were found in children with hyperactive type. We also found that there was a significant negative correlation between social, school, and activities according to CBCL and severity of ADHD according to Conner’s scale (Teacher and Parent edition). As regards ADHD patient’s and problems parameters of CBCL (internalizing and externalizing), it was found that ADHD children with inattentive type had the worst scores in internalizing problems, depressive and anxiety symptoms unlike ADHD children with hyperactive type who had better scores in internalizing problems. In addition, it was found that ADHD children with inattentive type had better scores in social problems, and aggressive behavior. ADHD children with combined type had the worst scores in aggressive behavior, role breaking behavior, social problems, and had better score in thought problems. ADHD children with hyperactive type had the worst scores in thought problems, and role breaking behavior. We also, found that there was a direct positive correlation between syndromic scales of CBCL (social problems, rule breaking behaviours and aggressive behaviours) and severity of ADHD according to Conner’s Rating Scale (Teacher and Parent edition) (P value <0.05) as increase in severity of ADHD was associated with more social, rule breaking and aggressive behaviours. fMRI In this study Rs-fMRI was used to evaluate functional connectivity in different brain circuits functional networks (i.e., the default mode, frontoparietal control, ventral attention, somatomotor, dorsal attention, visual networks, and cerebellum). And we found statistically significant functional connectivity changes in children and adolescents with ADHD compared to individuals without ADHD using both BOLD technique and ASL technique. We also studied the different connectivity patterns in both ADHD combined type and inattentive type, revealing different cerebral mapping in both types. In children with ADHD (combined type) brain areas with significantly reduced resting-state brain activity include bilateral Inferior frontal gyrus, Superior frontal gyrus, Middle frontal gyrus, Lateral prefrontal gyrus, Superior temporal gyrus, Inferior temporal gyrus, Inferior Parietal gyrus, ACG, PCC, Precuneus, Pyramis, Parahippocampal gyrus, Caudate, Putamen Thalamus, Fusiform gyrus, Precentral gyrus, Postcentral gyrus (sensorymotor area) and, Cerebellum. In children with ADHD (inattentive subtype) brain areas with significantly reduced resting-state brain activity include bilateral Inferior frontal gyrus, Superior frontal gyrus, Middle frontal gyrus, Lateral prefrontal gyrus, Superior temporal gyrus, Inferior temporal gyrus, Middle temporal gyrus, Caudate, Putamen, Thalamus, Pyramis, Precuneus, Cerebellum (posterior lobe) and, Cerebellum (anterior lobe). In children with ADHD (inattentive subtype) brain areas with significantly increased resting-state brain activity include Bilateral Cuneus, Culmen, bilateral Lingual gyrus, bilateral Posterior medial frontal gyrus, Inferior Parietal gyrus, bilateral Posterior medial frontal gyrus and, Parahippocampal gyrus. Increase in severity of ADHD was associated with increase abnormalities in Functional connectivity of the following regions bilateral Inferior frontal gyrus, Superior frontal gyrus, Middle frontal gyrus, Lateral prefrontal gyrus, Middle temporal gyrus, Caudate, Putamen, Thalamus, Precuneus, Cerebellum (posterior Caudate, Putamen, Thalamus, Precuneus, Cerebellum (posterior lobe), Cerebellum (anterior lobe), Superior temporal gyrus, Inferior temporal gyrus, bilateral Cuneus, Lingual gyrus, bilateral Posterior medial frontal gyrus, Inferior Parietal gyrus, bilateral Posterior medial frontal gyrus, Para hippocampal gyrus, Precentral gyrus and, Postcentral gyrus. In comparison to typically developed normal health control subjects, children with ADHD showed significant reduction in the regional cerebral blood flow particularly in the left cerebral hemisphere. In children with ADHD there was a significant reduction in cerebral blood flow to the following brain regions bilateral Inferior frontal gyrus, Superior frontal gyrus, Middle frontal gyrus, Lateral prefrontal gyrus, Superior temporal gyrus, Inferior temporal gyrus, Middle temporal gyrus, Caudate, Putamen, Thalamus, Pyramis, Precuneus, and Cerebellum. This reduction in cerebral blood flow also was statistically significant with increase in severity of ADHD. And, we found a significant reduction in cerebral blood flow to the following regions bilateral Inferior frontal gyrus, Superior frontal gyrus, Middle frontal gyrus, Lateral prefrontal gyrus, Superior temporal gyrus, Inferior temporal gyrus, Middle temporal gyrus, Caudate, Putamen, Thalamus, Pyramis, Precuneus, and Cerebellum. This reduction in cerebral blood flow also was statistically significant with increase in severity of ADHD. Our results could help in further future studies using fMRI in ADHD classification beside clinical and psychometric classification. Also, we proved that the more clinical symptoms become sever the more impairment occur in functional connectivity.