Inattentive ADHD Research Articles

The Associations Between Sluggish Cognitive Tempo, Internalizing Symptoms, and Academic Performance in Children With Reading Disorder: A Longitudinal Cohort Study

Objective: To investigate whether sluggish cognitive tempo (SCT) was associated with anxiety, depression, and academic performance (AP) in children with reading disorder (RD), and whether ADHD-Inattention (ADHD-IN) moderated these relationships. Method: Parents and teachers of children with RD (N = 147, ages 6–18) completed evaluations of SCT, ADHD, anxiety, depression, and AP, every 3 months for 18 months. Baseline and longitudinal associations between SCT and outcomes, and effect moderation of ADHD-IN, were assessed. Results: Teacher-rated SCT was positively associated with teacher-rated anxiety (p < .001) and negatively associated with AP (p < .001) cross-sectionally and longitudinally, with significant effect modification by ADHD-IN for both outcomes. SCT was not associated with depression in adjusted cross-sectional and longitudinal analyses. There were no significant findings for any parent-reported measures. Conclusion: SCT has negative effects on anxiety and AP in children with RD among individuals with low ADHD-IN according to teacher report. Targeted treatment of SCT may provide substantial benefits.

ADHD-inattentive versus ADHD-Combined subtypes: A severity continuum or two distinct entities? A comprehensive analysis of clinical, cognitive and neuroimaging data

The current study aimed to explore the multimodal differences between the inattentive ADHD (ADHD-I) subtype and the combined ADHD (ADHD-C) subtype. A large sample of medication-naïve children with pure ADHD (i.e., without any comorbidity) (145 with ADHD-I, 132 with ADHD-C) and healthy controls (n = 98) were recruited. A battery of multiple scales and cognitive tests were utilized to assess the clinical and cognitive profiles of each individual. In addition, structural and diffusion magnetic resonance imaging (MRI) were acquired for 120 subjects with ADHD and 85 controls. Regional gray matter volume, white matter volume, and diffusion tensors, e.g., axial diffusivity (AD), were compared among the three groups in a whole-brain voxel-wise manner. Compared with healthy controls, both ADHD groups exhibited elevated levels of behavioral and emotional problems. The ADHD-C group had more behavioral problems and emotional liability, as well as less anxiety, than the ADHD-I group. The two ADHD groups were equally impaired in most cognitive domains, with the exception of sustained attention. Compared with healthy controls, the ADHD-C group showed a high gray matter volume (GMV) in the bilateral thalamus and a high white matter volume in the body of the corpus callosum, while the ADHD-I group presented an elevated GMV mainly in the left precentral gyrus and posterior cingulate cortex. Compared with participants with ADHD-C and healthy controls, subjects with ADHD-I showed increased AD in widespread brain regions. Our study has revealed a distinct, interconnected pattern of behavioral, cognitive, and brain structural characteristics in children with different ADHD subtypes.

Longitudinal Temperament Pathways to ADHD Between Childhood and Adolescence.

The current investigation extended prior cross-sectional mapping of etiological factors, transdiagnostic effortful and affective traits, and ADHD symptoms to longitudinal pathways extending from two etiological domains: polygenic and prenatal risk. Hypotheses were (1) genetic risk for ADHD would be related to inattentive ADHD symptoms in adolescence and mediated by childhood effortful control; (2) prenatal smoking would be related to hyperactive-impulsive ADHD symptoms during childhood and mediated by childhood surgency; and (3) there would be age-related variation, such that mediation of genetic risk would be larger for older than younger ages, whereas mediation of prenatal risk would be larger in earlier childhood than at later ages. Participants were 849 children drawn from the Oregon ADHD-1000 Cohort, which used a case control sample and an accelerated longitudinal design to track development from childhood (at year 1 ages 7-13) through adolescence (at year 6 ages 13-19). Results showed the mediational pathway from prenatal smoking through surgency to hyperactivity-impulsivity at Year 1 was significant (indirect effect estimate = .053, p < .01). The mediational pathway from polygenic risk through effortful control to inattention at Year 6 was also significant (indirect effect estimate = .084, p < .01). Both results were independent of the association between inattention and hyperactivity-impulsivity and control for the alternative etiological input and held across parent- and teacher-report of ADHD symptoms. In line with dual pathway models of ADHD, early prenatal risk for hyperactivity-impulsivity appears to operate through surgency, while polygenic genetic risk for inattention appears mediated by effortful control.

A-138 The Correlation between Inattentiveness and Depression in an Adult Population Sample

Abstract Objective To test if there is a correlation between the inattentive domain of the Conners Continuous Performance Task 3rd Edition (CPT-3) and depression scale of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Method Adult mixed psychiatric clinical sample was derived from a large de-identified database through a SPSS descriptive statistics analysis. Participants (n = 256) were a diverse distribution of race (62.1%Caucasian,16%Latinx,12.9%African American, and 9%Other), gender (60.5%female, 39.5%male), age (27.25-years average), and education (16-years average). Each participant was administered the Conners CPT-3 to evaluate the inattentive domain which consisted of Detectability, Omissions, Commission, Hit-Reaction-Time (HRT), HRT-Standard-Deviation, and Variability; and the MMPI-2. A bivariate correlation was run to determine significance. Results The CPT-3 and MMPI-2 were correlated at p &amp;lt; 0.01 significantly on Variability with the K-Scale (r = −1.69) and VRIN-Scale (r = 0.177). They were correlated at p &amp;lt; 0.05 significantly on Variability with the TRIN-Scale (r = 0.126) and 2-Scale (r = 0.152); on HRT-Std-Dev with the TRIN-Scale (r = 0.127) and 1-Scale (r = 0.128); on Omissions with the VRIN-Scale (r = 0.151) and 9-Scale (r==0.126); and on Commissions with the 7-Scale (r = −0.124) and 8-Scale (r = −0.124). Conclusion Mitchell et al. (2013) conducted a study to assess the relationship between ADHD and negative automatic thoughts associated with depression in adults which found that inattentive ADHD significantly associated with negative automatic thoughts. Although the current analysis found some correlation between the measures, there was a lack of significant correlation between inattentiveness and depression. These findings are important as they contradict a criteria for depression. Further research is needed to understand the dynamic between the two measures.

Hair cortisol concentration and neurocognitive functions in preschool children at risk of developing attention deficit hyperactivity disorder

ObjectiveSex differences have been shown in the relation between hair cortisol concentration (HCC) and ADHD symptoms. As an extension of these findings, we analyze whether a child’s sex modulates the associations between HCC and ADHD-related neurocognitive functions. MethodsA community-based sample of 122 children was tested at age 4–5 (T1) and 8 (T2) years. At T1 and T2, ADHD symptoms were assessed with clinical parent interviews and parent and teacher questionnaires. Neurocognitive functions (i.e. T1: inhibitory control, working memory (WM), T2: verbal and performance intelligence (IQ-p)) were assessed using (neuro-)psychological tests. At T1, HCC was analyzed in the most proximal 3 cm scalp hair segment using luminescence immunoassay. ResultsExclusively in boys, low HCC correlated with low WM and IQ-p. The sex-by-HCC interaction effect on WM was significant. In boys, HCC completely explained the links of ADHD inattention symptoms with WM and IQ-p, respectively. ConclusionResults suggest a specific neurocognitive/endocrine profile in preschool boys at risk of developing ADHD, comprising hypocortisolism combined with memory and attention deficits.

Does Cannabis, Cocaine and Alcohol Use Impact Differently on Adult Attention Deficit/Hyperactivity Disorder Clinical Picture?

While the association between adult Attention Deficit/Hyperactivity Disorder (A-ADHD) and Substance Use Disorders (SUDs) has been widely explored, less attention has been dedicated to the various substance use variants. In a previous paper, we identified two variants: type 1 (use of stimulants/alcohol) and type 2 (use of cannabinoids). In this study, we compared demographic, clinical and symptomatologic features between Dual Disorder A-ADHD (DD/A-ADHD) patients according to our substance use typology, and A-ADHD without DD (NDD/A-ADHD) ones. NDD patients were more frequently diagnosed as belonging to inattentive ADHD subtype compared with type 1 DD/A-ADHD patients, but not with respect to type 2 DD/ADHD. NDD/A-ADHD patients showed less severe symptoms of hyperactivity/impulsivity than DD/A-ADHD type 1, but not type 2. Type 1 and type 2 patients shared the feature of displaying higher impulsiveness than NDD/A-ADHD ones. General psychopathology scores were more severe in type 2 DD/ADHD patients, whereas type 1 patients showed greater similarity to NDD/A-ADHD. Legal problems were more strongly represented in type 1 than in type 2 patients or NDD/A-ADHD ones. Our results suggest that type 1 and type 2 substance use differ in their effects on A-ADHD patients—an outcome that brings with it different likely implications in dealing with the diagnostic and therapeutic processes.

Sluggish Cognitive Tempo Factors in Emerging Adults:Symptomatic and Neuropsychological Correlates

ABSTRACT We examined whether there are factors of SCT in nonclinical young adults and whether SCT factors show differential relationships with depression, anxiety, ADHD, and executive functioning as assessed by self-report (EF-SR) or neuropsychological performance (EF-NP). Factor analysis revealed Daydreaming/Bored (D/B), Lethargy (L), and Cognitive Complaints (CC) factors. CC was associated with anxiety and D/B with depression. CC and D/B were associated with inattentive ADHD, while D/B was associated with hyperactive/impulsive ADHD. While all factors were associated with EF-SR, there were few relationships with EF-NP. Higher CC was associated with lower intellect, and higher D/B was related to better working memory.

Assessing sluggish cognitive tempo and ADHD inattention in elementary students: Empirical differentiation, invariance across sex and grade, and measurement precision.

To advance the research examining the sluggish cognitive tempo (SCT) construct, a key priority has been to develop assessment tools that are reliable and valid. The current study builds upon existing work by conducting the most thorough psychometric evaluation to date of the teacher-reported Child and Adolescent Behavior Inventory (CABI) SCT and attention-deficit/hyperactivity disorder inattention (ADHD-IN) modules in a large sample of elementary students. Participants were 7,613 students (Grades 2-5; 50.3% boys) attending 24 elementary schools in 3 school districts. Teachers (N = 398) provided ratings of SCT, ADHD-IN, academic impairment, and social impairment. An a priori 2-factor model with cross-loadings found the SCT items to demonstrate excellent structural validity with ADHD-IN items. The measurement properties of the SCT and ADHD-IN constructs were also invariant across sex and grade. SCT and ADHD-IN were both uniquely associated with academic and social impairment. Graded response item response theory analysis indicated that the SCT and ADHD-IN scales provided a high level of information and precision. The current study replicates and extends previous research and provides the strongest psychometric evidence to date of teacher-rated SCT using the CABI. The teacher-report CABI may be especially useful in the school-based screening of SCT and ADHD-IN. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Computer aided diagnosis system using deep convolutional neural networks for ADHD subtypes

BackgroundAttention deficit hyperactivity disorder (ADHD) is a ubiquitous neurodevelopmental disorder affecting many children. Therefore, automated diagnosis of ADHD can be of tremendous value. Unfortunately, unlike many other applications, the use of deep learning algorithms for automatic detection of ADHD is still limited. MethodIn this paper, we proposed a novel computer aided diagnosis system based on deep learning approach to classify the EEG signal of Healthy children (Control) from ADHD children with two subtypes of Combined ADHD (ADHD-C) and Inattentive ADHD (ADHD-I). Inspired by the classical approaches, we proposed a deep convolutional neural network that is capable of extracting both spatial and frequency band features from the raw electroencephalograph (EEG) signal and then performing the classification. ResultWe achieved the highest classification accuracy with the combination of β1, β2, and γ bands. Accuracy Recall, Precision, and Kappa values were %99.46, %99.45, %99.48, and 0.99, respectively. After investigating the spatial channels, we observed that electrodes in the Posterior side had the most contribution. ConclusionsTo the best of our knowledge, all previous multiclass studies were based on fMRI and MRI imaging. Therefore, the presented research is novel in terms of using a deep neural network architecture and EEG signal for multiclass classification of ADHD and healthy children with high accuracy.

Diagnostic delay in ADHD: Duration of untreated illness and its socio-demographic and clinical predictors in a sample of adult outpatients.

To investigate the Duration of Untreated Illness (DUI) and its socio-demographic and clinical predictors in a sample of adult ADHD outpatients. The DUI of 150 adult outpatients with a confirmed diagnosis of DSM-IV ADHD was calculated. Non-parametric tests were used to evaluate differences in DUI among subgroups and to build a correlation matrix. Subsequently, a multiple linear regression model was performed. The median DUI was 17 years (interquartile range [IQR]=14). DUI was longer in employed patients, those with a family history of ADHD, those with a history of major depressive disorder and those who had predominantly inattentive ADHD in childhood. The current age, age at administration of the first proper treatment and education level were correlated with DUI. Current age (63.3% of total variance), family history of ADHD and the presence of a predominantly inattentive type in childhood (together, 2.6% of total variance) were all predictors of DUI. Information programmes for caregivers and training for health care professionals should be promoted to foster the early recognition of covert inattentive symptoms and shorten DUI.

Adaptive functioning in children and adolescents with Trisomy X: An exploratory analysis.

Identifying the factors related to adaptive functioning will improve the information available to families and providers of females with Trisomy X. Cognitive and behavioral features were assessed in 50 females ages 12.2 ± 3.6 years using the Behavior Assessment System for Children Second Edition (BASC-2) and Wechsler Scales of Intelligence. Executive functioning, social skills, and autistic traits were evaluated in a subset. Adaptive functioning was assessed using the BASC-2 adaptive skills composite score (ASC). Participants were classified as average adaptive skills (ASC T-score > 40) or deficits (ASC T-score < 40). Group comparisons were conducted. Multiple linear regression examined which factors contributed to ASC score. Twenty-eight females (55.6%) had adaptive skills deficits with functional communication being the most commonly affected adaptive domain. The group with ASC in the average range had higher verbal IQ (VIQ) and lower rates of numerous behavioral concerns. Internalizing behavior composite, DSM-IV inattentive symptoms score, and VIQ were significant predictors of ASC. Prenatally diagnosed females comprised over 70% of those with average adaptive skills. In this study, internalizing behaviors, inattentive ADHD symptoms, and VIQ were associated with poorer adaptive functioning. Early interventions targeting internalizing behaviors, attention/executive functioning, and communication skills may improve adaptive skills and deserve further study.

Predictor Selection Using Lasso to Examine the Association of Motor Proficiency, Postural Control, Visual Efficiency, and Behavior With the Academic Skills of Elementary School-Aged Children

The associations between motor proficiency, postural control, and visual efficiency with teacher and parent ratings of children’s behavior and academic skills were examined among a sample of elementary school-aged children (N = 50). Teacher and parent ratings of students’ academic skills were analyzed separately to examine the predictive nature of measures of motor proficiency. Spearman rank order correlations reported low to moderate relationships between motor proficiency, postural control, and children’s behavior (e.g., ADHD inattention) and academic skills. The least absolute shrinkage and selection operator (lasso) procedure is demonstrated as an approach for variable selection of measures of children’s motor proficiency, postural control, and visual efficiency to predict academic skills. For teacher and parent ratings of academic skills, ADHD symptom of inattention was the strongest model predictor, whereas directional control (postural control) was also a predictor for parent ratings. Study findings shed light on practical and methodological factors associated with motor skills in educational contexts.

Supplemental Material for Assessing Sluggish Cognitive Tempo and ADHD Inattention in Elementary Students: Empirical Differentiation, Invariance Across Sex and Grade, and Measurement Precision

Supplemental Material for Assessing Sluggish Cognitive Tempo and ADHD Inattention in Elementary Students: Empirical Differentiation, Invariance Across Sex and Grade, and Measurement Precision

Sluggish Cognitive Tempo in Adolescents with and without ADHD: Differentiation from Adolescent-Reported ADHD Inattention and Unique Associations with Internalizing Domains.

A growing number of studies support the internal and external validity of youth self-reported sluggish cognitive tempo (SCT) symptoms. However, no study has examined SCT in adolescents without ADHD, examined whether adolescent self-reported SCT is distinct from adolescent self-reported ADHD inattention (ADHD-IN), or evaluated whether links between SCT and internalizing problems differ for adolescents with or without ADHD. The present study is the first to (1) determine the convergent and discriminant validity of self-reported SCT and ADHD-IN symptoms in both adolescents with and without ADHD, (2) test the invariance of SCT and ADHD-IN symptoms across ADHD and comparison groups, (3) examine SCT as uniquely related to a range of internalizing-relevant domains, and (4) evaluate if the association between SCT with internalizing correlates differs for adolescents with or without ADHD. Participants were adolescents (Mage=13years) with (n=162) and without (n=140) ADHD. Adolescents and parents completed measures of internalizing symptoms and emotion dysregulation; adolescents completed measures of rumination and suicidal ideation. Analyses indicated that 13 of the 15 SCT items demonstrated convergent and discriminant validity from ADHD-IN, and SCT and ADHD-IN demonstrated invariance across the ADHD and comparison groups and across sex. SCT, but not ADHD-IN, was uniquely associated with greater adolescent-reported internalizing symptoms and suicidal ideation. Both SCT and ADHD-IN were uniquely associated with adolescent-reported emotion dysregulation and parent-reported internalizing symptoms. Only ADHD-IN was uniquely associated with parent-reported emotion dysregulation. Findings support the differentiation of adolescent-reported SCT and ADHD-IN and demonstrate associations between SCT and increased internalizing problems in adolescents with and without ADHD.

5.9 SYMPTOM PROFILES AND MEDICATION TREATMENT PATTERNS IN A CLINICAL SAMPLE OF CHILDREN WITH ADHD VERSUS ASD

Studies show that the vast majority of children with ASD have ADHD, and children with both ADHD-Combined (ADHD-C) and ASD have high rates of oppositional, aggressive, and irritable behavior. Despite the similarity of symptoms that are the target of common treatment, the levels of impairment and prescribing practices may differ between the groups, although this has not been examined systematically in children with ADHD-C, ADHD-Inattentive (ADHD-I), and ASD.

6.45 EFFICACY STUDY OF AN OMEGA-3/6 COMBINATION FOR MILD- TO MODERATE-INATTENTIVE ADHD: A RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL IN ITALIAN CHILDREN

ADHD treatment is based on a multimodal approach that combines behavioral and pharmacological treatment. Recently, there has been a growing interest in dietary supplementation of polyunsaturated fatty acids (PUFAs), such as omega-3 and omega-6 that showed that they are possibly effective in the control of inattentive symptoms. A specific omega-3/6 combination dietary supplement therefore was administered to a sample group of Italian children with ADHD-Inattentive (ADHD-I) presentation to evaluate its clinical efficacy and effects on essential fatty acid (EFA) plasma levels.

The relations between abnormal sensory processing patterns and ADHD subtypes compared with a healthy control group Ryder Chen Ohana Kari and Shahien Radi

ADHD is an early childhood neurodevelopmental disorder with an estimated prevalence of 5.9%–7.1%. Sensory processing disorder (SPD), another early childhood developmental disorder, received much less attention. The prevalence of SPD may be as high as ADHD in the pediatric population and it is estimated to be highly co-morbid with ADHD. Many ADHD patients who suffer from co-occurring sensory processing symptoms in adulthood do not receive an SPD diagnosis and therefore may not receive eligible treatment. The study aimed to evaluate the co-occurrence of SPD’s different modalities among different subtypes of ADHD in adult population and to compare it with a healthy control group. A total of 60 individuals between 18 and 45 years of age, were divided into two groups: the DHD group (n = 30) and a healthy control group (n = 30). The participants completed questionnaires regarding ADHD in adulthood and SPD symptoms and subtypes. The results of sensory profile in different subtypes of ADHD were statistically analyzed and compared with control group. Individuals suffering from combined type ADHD were found having more frequent and extreme reactions (both hyper- and hypo sensitivity) to sensory stimuli compared to healthy controls and individuals with inattentive type ADHD. This study’s results emphasizes the importance of utilizing the SPD questionnaire among adult patients who seek neurological or mental treatment as part of the medical intake and thus should further be considered for inclusion in a standard DSM-VI adult diagnosis as a disorder whose impact continues to adulthood.

C-41 Functional Impairments in Girls with Attention-Deficit Hyperactivity Disorder

Abstract Objective ADHD is a neurodevelopmental disorder known to cause functional impairments. Few studies have identified impairments specific to girls with ADHD. The objective of this study was to explore the relationship between ADHD subtypes and measures of functional impairment in girls. Method Participants were chosen from a sample of girls ages 5 – 18 years old, diagnosed with ADHD at an outpatient ADHD clinic at a large children’s hospital (N = 303). Measures included parent and teacher BASC subscales of adaptability, homework problems, and comorbid clinical diagnoses based on the diagnostic interview for children and adolescents-revised parent version (DICA-R). Potential relationships between impairment measures and ADHD subtypes were assessed using multiple and logistic regressions to control for age and socioeconomic status (SES). Results Number of inattentive ADHD symptoms correlates positively with DICA diagnosis of ODD (x2 = 4.008, p = 0.045) and homework problems (r = 0.227, p = 0.0001). Number of combined ADHD symptoms is positively associated with DICA diagnosis of ODD (x2 = 26.812, p = 0.0001) and homework problems (r = 0.171, p = 0.0001) and negatively associated with parent reported social skills (r = 0.092, p = 0.006), adaptability (r = 0.146, p = 0.001) and teacher reported adaptability (r = 0.057, p = 0.01), after controlling for age and SES. Discussion Girls with ADHD exhibit functional impairments in the domains of comorbid diagnoses, homework problems, parent and teacher report of adaptability, and parent report of social skills. Additional research should include self-reports of functional impairment to determine self-perception of impairment.

Psychometric properties of a sluggish cognitive tempo scale in Japanese adults with and without ADHD.

This study examined the psychometric properties, convergent validity, and divergent validity of a Japanese translation of Barkley (The Barkley adult ADHD rating scale-IV, Guilford Press, New York, 2011) rating scale for assessing sluggish cognitive tempo (SCT) in adults. In total, 429 Japanese adults participated across three samples: 26 diagnosed with attention-deficit/hyperactivity disorder (ADHD; ages 19-50), 81 adults without ADHD (ages 22-65), and 322 university students (ages 18-27). All participants completed rating scales of SCT, ADHD, anxiety, and depressive symptoms. A subset of participants completed the SCT measure at two time points two weeks apart. The SCT measure (5 items) showed acceptable levels of internal consistency and test-retest reliability. This scale also demonstrated convergent and discriminant validity, as evidenced by factor analyses between SCT and ADHD inattention (ADHD-IN) symptoms as well as adequate fit of a four-factor model involving SCT, ADHD-IN, ADHD-hyperactivity/impulsivity (ADHD-HI), and internalizing symptoms. Additionally, SCT and ADHD-IN dimensions were differentially associated with ADHD-HI and internalizing factors. The ADHD group scored higher on SCT ratings compared to the student and adult non-ADHD groups even after controlling for the severity of ADHD and internalizing symptoms. The 5-item SCT measure appears reliable and demonstrates preliminary evidence of validity in Japanese adults, providing initial support for the transcultural validity of the SCT construct. Additional studies are needed to further evaluate the SCT items that did not meet criteria for convergent and discriminant validity in the current study, and to examine functional outcomes of individuals recruited based on clinically elevated SCT symptoms.

Plasma poly-unsatured fatty acids profile in children with inattentive ADHD - preliminary results of an efficacy Italian study with omega 3/6

Symptomatic full-thickness rotator cuff (RC) tears are often recommended for surgical repairs. However, some patients decide not to have surgery. The aim of this study was to see if there was any difference in preoperative variables between the two groups.137 consecutive patients recommended for surgery due to symptomatic full-thickness RC tear were evaluated. At mean 58.1 months after surgery-recommendation, the patients were asked whether they had surgery and their clinical outcome was assessed. Variables at the time of surgery-recommendation including demographics, range-of-motion (ROM), tear size, and fatty infiltration on MRI, and clinical score were compared between the two groups.The 59 men and 78 women had a mean age of 64.4 years. Overall, 104 (75.9%) patients were treated with RC repair and 33 (24.1%) were not. The main three reasons for not having surgery were improvement of symptoms or minimal pain (55%), economic burden (12%), and concern for postoperative long rehabilitation (9%). Demography and ROM measured at the time of surgery-recommendation did not differ. All clinical scores at one year and final follow-up survey showed no difference between the two groups. The Constant and UCLA scores at the time of surgery-recommendation were significantly higher and tear size was smaller in the ‘No-surgery’ group. Fatty infiltration of supraspinatus (2.0 versus 1.2, p < 0.001) and global fatty degeneration index (1.4 versus 0.8, p = 0.011) were statistically lower in ‘No-surgery’ group as well.Patients with relatively preserved function and small size tear tend to select non-surgical treatment and lead to relatively good outcome.