Deficits In ADHD Research Articles

Reduced temporal and spatial stability of neural activity patterns predict cognitive control deficits in children with ADHD.

This study explores the neural underpinnings of cognitive control deficits in ADHD, focusing on overlooked aspects of trial-level variability of neural coding. We employed a novel computational approach to neural decoding on a single-trial basis alongside a cued stop-signal task which allowed us to distinctly probe both proactive and reactive cognitive control. Typically developing (TD) children exhibited stable neural response patterns for efficient proactive and reactive dual control mechanisms. However, neural coding was compromised in children with ADHD. Children with ADHD showed increased temporal variability and diminished spatial stability in neural responses in salience and frontal-parietal network regions, indicating disrupted neural coding during both proactive and reactive control. Moreover, this variability correlated with fluctuating task performance and with more severe symptoms of ADHD. These findings underscore the significance of modeling single-trial variability and representational similarity in understanding distinct components of cognitive control in ADHD, highlighting new perspectives on neurocognitive dysfunction in psychiatric disorders.

Working memory and inhibitory control deficits in children with ADHD: an experimental evaluation of competing model predictions.

Children with ADHD demonstrate difficulties on many different neuropsychological tests. However, it remains unclear whether this pattern reflects a large number of distinct deficits or a small number of deficit(s) that broadly impact test performance. The current study is among the first experiments to systematically manipulate demands on both working memory and inhibition, with implications for competing conceptual models of ADHD pathogenesis. A clinically evaluated, carefully phenotyped sample of 110 children with ADHD, anxiety disorders, or co-occurring ADHD+anxiety (Mage=10.35, 44 girls; 69% White Not Hispanic/Latino) completed a counterbalanced, double dissociation experiment, with two tasks each per inhibition (low vs. high) x working memory (low vs. high) condition. Bayesian and frequentist models converged in indicating that both manipulations successfully increased demands on their target executive function (BF10>5.33x108, p<.001). Importantly, occupying children's limited capacity working memory system produced slower response times and reduced accuracy on inhibition tasks (BF10>317.42, p<.001, d=0.67-1.53). It also appeared to differentially reduce inhibition (and non-inhibition) accuracy for children with ADHD relative to children with anxiety (BF10=2.03, p=.02, d=0.50). In contrast, there was strong evidence against models that view working memory deficits as secondary outcomes of underlying inhibition deficits in ADHD (BF01=18.52, p=.85). This pattern indicates that working memory broadly affects children's ability to inhibit prepotent tendencies and maintain fast/accurate performance, and may explain the errors that children with ADHD make on inhibition tests. These findings are broadly consistent with models describing working memory as a causal mechanism that gives rise to secondary impairments. In contrast, these findings provide evidence against models that view disinhibition as a cause of working memory difficulties or view working memory as a non-causal correlate or epiphenomenon in ADHD.

Does Anxiety Systematically Bias Estimates of Executive Functioning Deficits in Pediatric Attention-Deficit/Hyperactivity Disorder?

Growing evidence suggests that childhood ADHD is associated with larger impairments in working memory relative to inhibition. However, most studies have not considered the role of co-occurring anxiety on these estimates - a potentially significant confound given prior evidence that anxiety may increase working memory difficulties but decrease inhibition difficulties for these children. The current study extends prior work to examine the extent to which co-occurring anxiety may be systematically affecting recent estimates of the magnitude of working memory/inhibitory control deficits in ADHD. The carefully-phenotyped sample included 197 children with ADHD and 142 children without ADHD between the ages of 8 and 13years (N = 339; Mage = 10.31, SD = 1.39; 144 female participants). Results demonstrated that ADHD diagnosis predicted small impairments in inhibitory control (d = 0.31) and large impairments in working memory (d = 0.99). However, child trait anxiety assessed dimensionally across multiple informants (child, parent, teacher) did not uniquely predict either executive function, nor did it moderate estimates of ADHD-related working memory/inhibition deficits. When evaluating anxiety categorically and controlling for ADHD, anxiety diagnosis predicted slightly better working memory (d = 0.19) but not inhibitory control for clinically evaluated children generally. Findings from the current study indicate that trait anxiety, measured dimensionally or categorically, does not differentially affect estimates of executive dysfunction in pediatric ADHD. Further, results suggest that trait anxiety is generally not associated with executive dysfunction above and beyond the impact of co-occurring ADHD. Future research is needed to further assess the role of anxiety in ADHD behavioral symptomatology, neurocognitive functioning, and mechanisms underlying these relations.

Processing Speed Deficit and Its Relationship with Math Fluency in Children with Attention-Deficit/Hyperactivity Disorder.

(1) To determine the processing speed (PS) deficit in children with ADHD; and (2) To investigate if PS deficit was the primary cause of daily dysfunction in ADHD by testing the direct and indirect effects via working memory (WM) of PS on math fluency (MF). Seventy-eight children (52 children with ADHD and 26 controls) were tested on their motor, perceptual, cognitive, and verbal PS, WM, and MF. Children with ADHD performed worse than controls on all PS, suggesting a general PS deficit. Moreover, cognitive PS was a significant predictor for MF. Mediation analysis showed that cognitive PS had direct and indirect effects via WM on MF, suggesting PS deficit might be the primary cause of MF difficulties in ADHD. Findings of this study suggested a general PS deficit in ADHD. Due to the importance of PS in MF, interventions for MF underachievers should include assessment and training of PS.

34.3 Social Skill Deficits in ADHD and Comorbid Disorders

34.3 Social Skill Deficits in ADHD and Comorbid Disorders

Reading assessment in ADHD and dyslexia in Brazilian teenagers

IntroductionAttention Deficit Hyperactivity Disorder (ADHD) and Dyslexia are among the most frequent developmental disorders in school-aged students, and both often cause an impact on scholar reading performance. Therefore, it is fundamental to trace the differential profile in reading performance in such diagnoses. Competent reading occurs through the interaction of several cognitive processes, such as decoding, fluency, and oral and reading comprehension, that should be assessed in an evaluation.ObjectivesThe study aimed to characterize the performance of students with ADHD and dyslexia.MethodsWe assessed 25 adolescents, aged between 11 and 14 years old, from 6th to 9th year of middle school of public and private schools in Brazil, divided into two groups: the group with ADHD (16 students) and the group with dyslexia (9 students). The diagnoses were established by a multidisciplinary center and there were no comorbidities for any case. The instruments used were: Comprehension Test of Words and Pseudowords II (TCLPP II) to assess decoding (indicate if the word is correct or incorrect); Reading Fluency Test (TFL) to assess fluency in single words and in text reading; Cloze Reading Comprehension Test (TCCL) to measure reading comprehension; and the WISC vocabulary subtest to assess auditory comprehension.ResultsNon-parametric analyzes revealed statistically significant differences in measures of textual comprehension, especially in the tasks that involved decoding and fluency processes, evidencing superior performance of the group with ADHD in these tests. Participants with dyslexia had a significantly higher performance in relation to the number of word omissions, that is, they had lower omission errors. There was no significant difference between groups in auditory comprehension.ConclusionsA differential profile was found in reading performance, consistent with the cognitive deficits classically pointed out in the literature for each diagnosis: phonological deficits in dyslexia, with problems in decoding and fluency; and attentional deficits in ADHD, with omission errors. In the comprehension measures, dyslexic group had significant lower performance than ADHD in the Cloze Reading Comprehension Test, but there was no difference in the Vocabulary subtest-WISC. An explanatory hypothesis is that, to understand the text, it is necessary to recognize the words previously, whereas, in the WISC, it is not necessary to read, since the questions are oral. These results corroborate the hypothesis that deficits in reading comprehension in dyslexia are more related to difficulties in word recognition and fluency skills than in general listening comprehension.Financial support: CAPES Proex [grant 0426/2021, no. 23038.006837/2021-73]; CNPq [grant 310845/2021-1]Disclosure of InterestNone Declared

Functional Near-Infrared Spectroscopy Evidence of Prefrontal Regulation of Cognitive Flexibility in Adults With ADHD

Background: Executive function (EF) deficit is considered to be a core cognitive deficit in ADHD. The current study combined functional near-infrared spectroscopy (fNIRS) and numerical switching tasks to investigate the cognitive flexibility of adult ADHD as an important part of EF. Material and Methods: The Wender Utah Rating Scale and the adult ADHD self-rating scale were respectively used to assess ADHD symptoms in childhood and adulthood. A 22 adults with ADHD and 24 healthy controls (HCs) participated in the large/small and odd/even switching tasks. Results: Behavioral results were indicative of the ADHD switch costs being lower than the HCs. The fNIRS results also showed that ADHD’s frontal eye field was over-activated both in magnitude and switched judgment tasks. The dorsolateral prefrontal cortex was also over-activated in magnitude judgment tasks. Conclusion: These results revealed that adults with ADHD’s cognitive flexibility performed better than the HCs, which result is different from mainstream ideas that EF is a core deficit in ADHD.

High Time Preference Is a Key Cognitive Deficit in ADHD: Impact on Daily Life, Impairments, and Life Expectancy

Free AccessHigh Time Preference Is a Key Cognitive Deficit in ADHD: Impact on Daily Life, Impairments, and Life ExpectancyRussell A. BarkleyRussell A. BarkleySearch for more papers by this authorPublished Online:November 2022https://doi.org/10.1521/adhd.2022.30.7.1PDFPDF PLUS ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutREFERENCESAmmous S. (2018). The Bitcoin Standard: The decentralized alternative to central bank. Wiley. Google ScholarBarkley R. A. (2012). Executive functions: What they are, how they work, and why they evolved. Guilford Publications. Google ScholarBarkley R. A. (2015). Health problems and related impairments in children and adults with ADHD. In Barkley R. A. (ed.) Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.) (pp. 267–313). Guilford Press. Google ScholarBarkley R. A. (2019). Neuropsychological testing is not useful in the diagnosis of ADHD: Stop it (or Prove It)! The ADHD Report, 27(2), 1–8. Link, Google ScholarBarkley R. A. (2020). ADHD adversely impacts health, mortality risk, and estimated life expectancy by adulthood. The ADHD Report, 28(4), 1–5. Link, Google ScholarBarkley R. A., Edwards G., , Laneri M., , Fletcher K., , & Metevia L. (2001). Executive functioning, temporal discounting, and sense of time in adolescents with attention deficit hyperactivity disorder and oppositional defiant disorder. Journal of Abnormal Child Psychology, 29, 541–556. Crossref, Google ScholarBarkley R. A., & Fischer M. (2019). Hyperactive child syndrome and estimated life expectancy at young adult follow-up: The role of ADHD persistence and other potential predictors. Journal of Attention Disorders, 23, 907–923. Crossref, Google ScholarBarkley R. A., , Murphy K. R., , & Fischer M. (2008). ADHD in adults: What the science says. Guilford Press. Google ScholarBogg T., & Roberts B. W. (2004). Conscientiousness and health-related behavior: A meta-analysis of the leading behavioral contributors to mortality. Psychological Bulletin, 130, 887–919. Crossref, Google ScholarDalsgaard S., , Ostergaard S. D., , Leckman J. F., , Mortensen P. B., , & Pedersen M. G. (2015). Mortality in children, adolescents and adults with attention deficit hyperactivity disorder: a nationwide cohort study. Lancet, 385, 2190–2196. Crossref, Google ScholarFuster J. (1989). The prefrontal cortex. Raven Press. Google ScholarGreen L., , Fry A. F., , & Myerson J. (1994). Discounting of delayed rewards: A life-span comparison. Psychological Science, 5, 33–36. Crossref, Google ScholarGreen L., , Myerson J., , Lichtman D., , Rosen S., , & Fry A. (1996). Temporal discounting in choice between delayed rewards; The role of age and income. Psychology and Aging, 11, 79–84. Crossref, Google ScholarLondon A. S., , & Landes S. D. (2016). Attention deficit hyperactivity disorder and adult mortality. Preventive Medicine, 90, 8–10. Crossref, Google ScholarNigg J. T. (2013). Attention-deficit/ hyperactivity disorder and adverse health outcomes. Clinical Psychology Review, 33, 215–228. Crossref, Google ScholarRachlin H., & Ranieri A. (1992). Irrationality, impulsiveness, and selfishness as discount reversal effects. In Loewenstein G., & Elster J., (Eds.), Choice over time (pp. 93–118). Sage. Google Scholar Next article FiguresReferencesRelatedDetails Volume 30Issue 7Nov 2022 Information© 2022 The Guilford PressKeywordsADHDtime preferencetemporal discountingimpairmentlife expectancyPDF download

1.93 Testing Continued Effectiveness Through Multiple Modifications of an Empirically Supported Treatment for Organization, Time Management, and Planning Deficits in ADHD and Related Disorders

Organizational skills training (OST) for youth with ADHD is an efficacious treatment that addresses impairments at home and in school. Modifications of OST were conducted to treat children with or without ADHD, to reduce treatment barriers, and to respond to changes in school demands during the COVID-19 pandemic.

0499 Sleep and Neurocognition in Adolescents with ADHD: A Polysomnographic Study

Abstract Introduction Sleep disturbances are common among adolescents with ADHD; however, few studies have characterized the nature of ADHD-related sleep problems using the gold-standard sleep measure, polysomnography (PSG), in adolescence. Additionally, although similar cognitive deficits are common across ADHD and sleep-disordered populations, the potential role of sleep in contributing to cognitive impairment in adolescent ADHD is unknown. This study investigates differences in PSG-measured sleep among adolescents with ADHD versus healthy controls without psychiatric disorders (HC) and associations with cognition. Methods Sixty-two adolescents aged 13-17 (31 ADHD, mean age=15.3, 50% female) completed a psychiatric evaluation and 3 nights of ambulatory PSG. Following the third night, participants completed the Cambridge Neuropsychological Test Automated Battery (CANTAB). Sleep variables were averaged over 3 nights. Linear regressions controlling for age and sex examined group differences in a range of traditional PSG and spectral EEG indices as well as relationships between PSG/spectral indices and cognition (two summary scores derived from CANTAB: response accuracy and response time) within the ADHD group. Results Adolescents with ADHD displayed reduced SWS% (F(3,51)=9.67, p=.003), increased N2% (F(3,51)=10.35, p=.002), increased relative sigma (F(3,47)=6.55, p=.01) and beta (F(3,47)=4.10, p&amp;lt;.05) power, and a trend toward reduced relative delta power (F(3,47)=2.95, p=.09) compared to HC. Within the ADHD group, greater REM% (r=.43), reduced N2% (r=-.55), greater relative delta power (r=.52), higher delta power peak (r=.56), steeper delta decline overnight (r=-.56), and reduced relative theta (r=-.53), beta (r=-.74), and gamma (r=-.67) power were associated with better response accuracy (p’s&amp;lt;.05). Greater relative delta (r=-.51), and reduced relative theta (r=.55) and beta (r=.63), power were associated with faster response times. Conclusion Although adolescents with ADHD did not differ from HC on traditional PSG measures (TST, WASO), they exhibited abnormalities in sleep stage distribution and non-REM EEG frequency spectral indices, including reduced SWS and low frequency power and increased stage 2 sleep and high frequency power overnight. Notably, similar parameters were associated with impaired cognition, suggesting sleep may contribute to cognitive deficits in ADHD. Future studies may clarify whether sleep plays a causal role in cognitive impairments in adolescent ADHD and if sleep treatments result in improved cognition in this population. Support (If Any) K23MH108704

Wrong Brains at the Wrong Time? Understanding ADHD Through the Diachronic Constitution of Minds

ObjectivesThe purpose of this theoretical analysis of current research on ADHD is to provide an account integrating executive functional profiles with its broader structural neurodevelopmental profile.MethodsComparative theoretical analyses between executive functional deficit disorder models of ADHD and results from default mode network fMRI data. This was followed by an analysis of the temporal profile of ADHD and phase synchronous neural assemblies.ResultsComparative analyses suggest disparities within executive functional deficit disorder models and discontinuities between executive functional and structural profiles of ADHD. Analysis of the temporal signature of ADHD provides a potential avenue for integrating different profiles by means of anchoring executive functions within inherent diachronic neurocognitive organization.ConclusionsThe analyses provided suggest that executive functional deficits in ADHD arise from much broader idiosyncrasies, rooted within the inherent diachronic organization of neurocognitive function, and whose challenges must be understood in conjunction with socio cultural environmental factors.

Time Perception Deficits in Children and Adolescents with ADHD: A Meta-analysis

Objective: Prior studies have reported time perception impairment in children and adolescents with ADHD but the results were inconsistent. Method: The current meta-analysis reviews 27 empirical studies published in English after year 2000 that compared time perception competence among children and adolescents with and without ADHD. Results: Results from 1620 participants with ADHD and 1249 healthy controls showed significant timing deficits in ADHD. Children/adolescents with ADHD perceived time less accurately (Hedges’ g > 0.40), less precisely (Hedges’ g = 0.66) and had higher tendency to overestimate time than their healthy counterparts. Moderator analyses indicated that the discrepancy of time perception between groups was not affected by the type of timing tasks nor the modality of stimuli used in the tasks. Nonetheless, results were moderated by age and gender. Conclusion: These findings may update current understanding of the underlying neuropsychological deficits in ADHD and provide insight for future research in clinical assessments and treatments for ADHD.

A Comparative Study of Neuro-cognitive Functioning of Children with and without ADHD on Cognitive Assessment System

Background: Applicability of the PASS model of cognitive deficit in ADHD has been widely discussed and supporting evidence has been gathered on the cognitive assessment system (CAS). Examination of the hypothesis on CAS still remains in infancy in India which further limits the clinical utility of the findings while planning neuro-cognitive interventions. The present study was thus conceived to assess neurocognitive functioning in young children between 6-11 years with a diagnosis of ADHD in comparison with those without ADHD. Method: A cross-sectional research design was adopted. Using purposive sampling, 90 participants were included which consisted of two groups, ADHD (N=45) and Non-ADHD (N=45). Coloured Progressive Matrices (CPM) was used for screening IQ while primary outcome measures included CAS, Porteus Mazes Test (PMT), and Children’s Trail Making Test (TMT). Using SPSS 24.0, socio-demographic comparison across two groups on categorical variables was done using chi-square analysis while an independent sample t-test was applied to compare scores on primary outcome measures. Results: Children with ADHD obtained significantly lower mean scores compared to children in the non-ADHD group across all domains of CAS. On PMT, the ADHD group committed a significantly greater number of errors and also took significantly more time to complete the test than the non-ADHD group. No significant group difference was obtained on TMT. Conclusion: Supportive evidence for the PASS model deficit was obtained in the present study. The diagnostic utility study of CAS on larger sample is further warranted to obtain norms for the Indian population. Keywords: Young Children, ADHD, Cognitive Assessment System, executive functioning

Context Regulation of Mind Wandering in ADHD

Objective We aimed to understand the association between MW frequency and clinical measures, context regulation of MW and group differences in task performance. Method 27 adults with ADHD and 29 controls performed tasks manipulating demand on working memory and sustained attention, and recorded their MW frequency using probes. Results A significant association between MW frequency and the clinical measures was demonstrated. Along with increased MW frequency, individuals with ADHD reported decreasing MW frequency during increasing demands on working memory (context regulation), but not on sustained attention (deficient context regulation). Controls, however, maintained continuous task focus across all conditions. Group differences in task performance were no longer significant after adding MW frequency as a covariate. Conclusion Deficient context regulation during increasing demands on sustained attention suggests that sustained attention deficits may play a more important role in regulation of MW in ADHD. MW frequency might also underpin performance deficits in ADHD.

ADHD and ASD: distinct brain patterns of inhibition-related activation?

Attention-deficit/hyperactivity (ADHD) and autism spectrum (ASD) disorders often co-occur. In both cases, response inhibition deficits and inhibition-related atypical brain activation have been reported, although less consistently in ASD. Research exploring the overlap/distinctiveness between ADHD and ASD has significantly increased in recent years, but direct comparison of the inhibition-related neuronal correlates between these disorders are scarce in the literature. This study aimed at disentangling the shared and specific inhibitory brain dysfunctions in ASD and ADHD. Using functional magnetic resonance imaging (fMRI), brain activity was compared between children with ADHD, ASD and typically developing (TD) children aged 8–12 years during an inhibition stop-signal task, using stringent inclusion criteria. At the behavioural level, only children with ADHD exhibited inhibition deficits when compared with the TD group. Distinct patterns of brain activity were observed during successful inhibition. In children with ADHD, motor inhibition was associated with right inferior parietal activation, whereas right frontal regions were activated in children with ASD. Between-group comparisons disclosed higher middle frontal activation in the ASD group compared with the ADHD and the TD groups. Our results evidence different patterns of activation during inhibition in these two disorders, recruiting different regions of the fronto-parietal network associated to inhibition. Besides brain activity differences, behavioural inhibition deficits found only in children with ADHD further suggest that reactive inhibition is one of the core deficits in ADHD, but not in ASD. Our findings provide further evidence contributing to disentangle the shared and specific inhibitory dysfunctions in ASD and ADHD.

Supplemental Material for Working Memory and Short-Term Memory Deficits in ADHD: A Bifactor Modeling Approach

Supplemental Material for Working Memory and Short-Term Memory Deficits in ADHD: A Bifactor Modeling Approach

The Effectiveness of a Comprehensive Intervention on Word Problem Solving for Elementary School Students with ADHD: POVM + Schema Based Word Problem Solving

When core mathematic instruction is not enough to address skill deficits of students with ADHD, more intensive interventions are required to support student learning and comprehensive interventions with strong instructional components may use to help improve achievement of students with mathematics difficulties. As individual components are found effective according to the literature, a combination of interventions may be used to develop a comprehensive treatment to enhance outcome for students with wide-ranging academic deficits in ADHD. This study aimed to extend the use of VBI by using POVM, schema based-word problem solving method and peer tutoring to teach change, group, and compare type addition-subtraction word problem solving to students with ADHD. The instruction was anchored in use of concrete representations of schema to model conceptual understanding of word problem solving. The video presentation of the instruction via POVM allows for development of procedural knowledge as participants can view instruction of problem-solving steps. A single-case multiple probe across participants, experimental design was used with three participants. Participants were given a laptop connected to headphones. The video was preloaded on the laptop and participants started and stopped the intervention independently. After watching the video, participants completed the three different types of word addition and subtraction problems independently. Sessions were monitored and videotaped by the author to ensure videos were viewed in their entirety and at least two weeks after completion of the intervention, participants were given a maintenance assessment. All participants were successful and shared that they enjoyed learning about word problem solving using the video instruction, supporting the social validity of this intervention.

Effects of Acute Aerobic Exercise on Response Inhibition in Adult Patients with ADHD

Previous studies suggest beneficial effects of aerobic exercise on executive functions, which are a core deficit in ADHD. The aim of the present fMRI study was to investigate acute effects of aerobic exercise on inhibitory control and related brain activation in adult patients with ADHD. 23 patients and 23 matched healthy controls performed on a Go/No-go task in an MRI scanner, following both, an exercise condition involving 30 min of cycling at moderate intensity, and a control condition. ADHD patients compared to healthy controls showed increased brain activation during successful inhibition in the exercise compared to the control condition in parietal, temporal, and occipital regions. Exercise did not improve behavioral performance in either group, but in ADHD patients, exercise-related increases in brain activation and behavioral task performance (i.e., correct inhibition rate) negatively correlated with correct inhibition rate in the control condition. Thus, patients with worse inhibition performance showed stronger exercise-related enhancements, indicating that the lack of improvements on the behavioral level for the whole patient group could be due to ceiling effects. Our findings might be an important step in understanding the neural basis of exercise effects and could, in the long term, help in developing alternative treatment approaches for ADHD.

37.1 ALPHA MODULATION DURING WORKING MEMORY ENCODING PREDICTS NEUROCOGNITIVE IMPAIRMENT IN ADHD

ADHD is associated with working memory (WM) deficits. However, WM is a multiprocess construct that can be impaired through several pathways, leaving the source of WM impairments in ADHD unresolved. In this study, we aim to replicate, in an independent sample group, previously reported deficits in component processes of WM deficits in ADHD and expand to consider their implications for neurocognitive outcomes.

66.5 ADDRESSING EXECUTIVE FUNCTIONING DEFICITS AND THE TRANSITION TO HIGHER LEARNING

Replicated findings indicate that those with ADHD frequently demonstrate deficits in executive functions (EF) (eg, problems with attention control, behavior control, working memory, and planning). Clinicians should have a clear understanding of the impact that these deficits have upon individual, family, and school functioning. This presentation will: 1) summarize investigations of EF deficits in ADHD; 2) show how EF deficits can affect daily functioning; 3) discuss limitations when broad and abstract methods for building skills in EF have been tried; and 4) review the findings of emerging treatments that address practical EF deficits that have contributed to improvements in organizational skills, family functioning, and school performance.