Neuroscience and Biobehavioral Reviews 140 (2022) 104769

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Neuroscience and Biobehavioral Reviews

journal homepage: www.elsevier.com/locate/neubiorev

Review Article

Half a century of research on Attention-Deficit/Hyperactivity Disorder: A

scientometric study
Samuele Cortese a, b, c, d, e, *, 1, Michel Sabé e, 1, Chaomei Chen g, Nader Perroud f,
Marco Solmi a, h, i, j, k
a
Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
b
Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, UK
c
Solent NHS Trust, Southampton, UK
d
Hassenfeld Children’s Hospital at NYU Langone, New York University Child Study Center, New York City, NY, USA
e
Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
f
Division of Psychiatric Specialties, Department of Psychiatry, University Hospitals of Geneva
g
College of Computing & Informatics, Drexel University, Philadelphia, PA, USA
h
Department of Psychiatry, University of Ottawa, Ottawa, ON, Canada
i
Department of Mental Health, The Ottawa Hospital, Ottawa, ON, Canada
j
Ottawa Hospital Research Institute (OHRI) Clinical Epidemiology Program, University of Ottawa, Ottawa, ON, Canada
k
Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany

A R T I C L E I N F O A B S T R A C T

Keywords: We performed a scientometric analysis of the scientific literature on ADHD to evaluate key themes and trends
ADHD over the past decades, informing future lines of research. We conducted a systematic search in Web of Science
Scientometrics Core Collection up to 15 November, 2021 for scientific publications on ADHD. We retrieved 28,381 publications.
Evidence synthesis
We identified four major research trends: 1) ADHD treatment, risks factors and evidence synthesis; 2) neuro­
Meta-analysis
Systematic review, CiteSpace
physiology, neuropsychology and neuroimaging; 3) genetics; 4) comorbidity. In chronological order, identified
clusters of themes included: tricyclic antidepressants, ADHD diagnosis/treatment, bipolar disorder, EEG, poly­
morphisms, sleep, executive functions, pharmacology, genetics, environmental risk factors, emotional dysregu­
lation, neuroimaging, non-pharmacological interventions, default mode network, Tourette, polygenic risk score,
sluggish cognitive tempo, evidence-synthesis, toxins/chemicals, psychoneuroimmunology, Covid-19, and phys­
ical exercise. In conclusion, research on ADHD over the past decades has been driven mainly by a medical model.
Whereas the neurobiological correlates of ADHD are undeniable and crucial, we look forward to further research
on relevant psychosocial aspects related to ADHD, such as societal pressure, the concept of neurodiversity, and
stigma.

1. Introduction youth* OR adolescent*) returned 10,767, 8439, 7393, and 1376 hits
when these terms were matched, respectively, with “autism”, “(ADHD
With an estimated worldwide prevalence around 5–7 % in school- OR Attention-Deficit/Hyperactivity Disorder OR Hyperkinetic Syn­
aged children (Polanczyk et al., 2007; Thomas et al., 2015), drome OR hyperkinetic disorder)”, “depression”, and “bipolar” (limiting
Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common the indexing of the terms in the title of the article).
neurodevelopmental disorder (Faraone et al., 2021). Impairing symp­ Scientometrics, i.e., bibliometrics when applied to science research,
toms of ADHD persist in adulthood in up to 60–70 % of cases (Sibley allows us to summarize large amount of bibliometric data in order to
et al., 2016). ADHD is also one of the most researched disorders in child present the state of knowledge and emerging trends of a research topic
and adolescent psychiatry. By way of comparison, a simple search in or field over time. To our knowledge, only three scientometric analyses
PubMed on 6 June 2022 using the search terms: (child OR children OR of the scientific literature specifically focused on ADHD have been

* Correspondence to: Centre for Innovation in Mental Health, University of Southampton, Highfield Campus Bldg. 44, Southampton SO17 1BJ, United Kingdom.
E-mail address: samuele.cortese@soton.ac.uk (S. Cortese).
1
Dr. Samuele Cortese and Dr. Michel Sabé share first authorship and contributed equally to this work.

https://doi.org/10.1016/j.neubiorev.2022.104769
Received 7 June 2022; Received in revised form 28 June 2022; Accepted 2 July 2022
Available online 4 July 2022
0149-7634/© 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
S. Cortese et al. Neuroscience and Biobehavioral Reviews 140 (2022) 104769

published. These previous analyses were limited in scope and in the time “trial”). In line with previous evidence synthesis in the field of ADHD
period considered. In the first one, López-Muñoz and colleagues (Cortese et al., 2017), we did not include terms related to Minimal Brain
(López-Muñoz et al., 2008) analyzed relevant articles on ADHD pub­ Dysfunction or Minimal Brain Disorder, which would not be comparable
lished between 1989 and 2005 and found an increase of the number of with DSM definitions of ADHD or equivalent ICD definitions of Hyper­
publications in the 25-year period considered, considered to be related kinetic Disorder, that were retained in our search. The full list of search
to the introduction of medications specifically approved for ADHD. They terms can be found in the study protocol. To assess the quality of the
also found the Journal of the American Academy of Child and Adolescent reference filtering process and the homogeneity of the dataset, in line
Psychiatry (JAACAP) and the USA to be, respectively, the scientific with previous studies (Moore et al., 2014), we tolerated a 5 % error by
journal with the highest number of publications on ADHD and the randomly subsampling 1000 references.
country with the largest scientific productivity on ADHD. The second A detailed report of the reason for excluding articles and the
study (Ghanizadeh and Akhondzadeh, 2010), restricted to ADHD pub­ extraction process is shown in the flowchart in the supplementary Fig 1.
lications from Iran up to 2009, found that a larger number of articles
were indexed in IRANMEDEX (62 %) than in MEDLINE (38 %). The third study 2.2. Measures
(Lin et al., 2021), limited to the top 100 articles on ADHD, by citations,
published in the period 2014–2020, found that the most frequent topics To identify research themes and trends, we used two measures:
covered by these highly cited paper related to the field of epidemiology
(28 %). The two most productive countries were the USA (42 %) and the 1) Co-citation reference (documents) network (commonly known as
UK (13 %). Most articles were published in JAACAP (15 %) and JAMA Document Co-Citation Analysis-DCA). Co-citation networks are
Psychiatry (9 %). formed based on co-citation relations, which connect a pair of doc­
However, whereas these previous publications provided insight on uments concurrently cited by a third document (Small, 1973).
specific aspects of the ADHD literature, a more comprehensive scien­ Co-citation networks extend from a single-slide equivalent to
tometric analysis has the potential to inform the field in terms of themes multiple-slice network analysis, i.e., a time series of networks in
that have been the focus of research in the past decades. Importantly, order to detect critical transitions over time more effectively. The
scientometric analyses can also reveal trends in the field, allowing us to co-citation reference network reflects the intellectual base
making predictions on the future of ADHD research. This is relevant for combining highly cited papers and research trends evolution,
researchers/clinicians as well as research funding bodies. Furthermore, whereas co-citation networks enriched by thematic patterns of citing
recently, scientometric approaches have been strengthened with the articles, such as the techniques used in this study, may highlight
inclusion of visualization and data mining techniques. These novel ap­ research fronts and scholarly impacts of the intellectual base.
proaches have not yet been applied to scientometric studies on ADHD. Co-citation references network allowed us also to estimate the
Therefore, we conducted a scientometric study according to state-of- so-called hotspots, i.e., units of measure (e.g., authors, references,
the-art methods with the primary objective to evaluate how research on countries, institutions or keywords) with significantly higher con­
ADHD has evolved over the past decades in terms of research topics nections relative to others.
addressed and trends. Our secondary aims were to measure research 2) Co-occurring networks of author-assigned keywords. Co-occurrence
performance and relevance in terms of countries, institutions, authors, analysis is the counting of paired data within a collection unit,
and journals and to assess possible future topics of interest in the field here keywords. The process of constructing co-occurrence networks
based on emerging trends. included identifying keywords in the text, calculating the frequencies
of keywords co-occurrences, and finding clusters of keywords in the
2. Methods network (Hofmann and Puzicha, 1998).

The study was conducted based on a pre-registered protocol Research weaving tools used in relation to co-citation reference
(https://osf.io/cy4v2/?view_onlY = efcc2c0a379c4fb1923c362 network and co-occurring authors’ keywords included Systematic map­
0d89e6056). The study protocol was informed by the concept of ping, Intellectual structure, Performance analysis, and Collaboration net­
‘research weaving’ proposed by Nakagawa et al. (2019), a new frame­ works (Table 1). In particular, we also reported intellectual turning point
work for research synthesis of both evidence and influence, accounting papers”, i.e., papers associated with significant contributions as a
for their trend over time. This framework summarizes and visualizes domain advance.
information on a collection of papers on any given topic. Research In relation to our secondary objectives, we estimated networks of co-
weaving combines the power of two methods: systematic mapping, which author’s country, networks of co-author’s institutions, journal co-
provides a snapshot of the current state of knowledge, identifying areas citation networks, co-authorship networks (accounting for the cooper­
that more research attention and those ready for full bibliometric syn­ ation between two or more researchers, which reflects the institution
thesis and bibliometrics, which shows how pieces of evidence are con­ and influence networks) and author co-citation analysis, which esti­
nected, revealing the structure and development of a scientific field. mates the intellectual structure of a field (the state of the knowledge)
based on co-citation relationships between the authors of the documents
2.1. Search strategy and data collection in that field (White and McCain, 1998). Author co-citation analysis as­
sumes that pairs of authors who are frequently cited by the same doc­
First, a comprehensive search for relevant terms in the titles, ab­ uments are more likely to produce semantically related research.
stracts, and keywords in the Web of Science Core Collection (WOSCC) was Research weaving tools used for the secondary objectives included
conducted on November 15, 2021. WOSCC permits to retrieve refer­ Performance Analysis and Collaborative (influence) network analysis
ences cited by published articles, and is considered the most informative (Table 1).
database for bibliometric analyses (Mongeon and Paul-Hus, 2016). The
database source was limited to the Science Citation Index-Expanded, with 2.3. Data analysis and software
no restrictions on publication date or language. Original articles, re­
views, editorials, including early access articles, were retained. The We used the Bibliometrix R package (3.1.4) to analyze the publica­
search was performed using a combination of keywords and MeSH terms tions, full references and citations of the retrieved articles, and Cite­
related to ADHD (or equivalent definitions such as Hyperkinetic syn­ Space (version 5.8. R3) to visualize and analyze trends and patterns in
drome and acronyms in languages other than English e.g., TDAH in the scientific literature on ADHD. Metrics used are reported in Table 1.
French and Spanish) and to the type of publication (e.g., ‘‘review” or Cluster labels were extracted from the keyword lists using log-

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S. Cortese et al. Neuroscience and Biobehavioral Reviews 140 (2022) 104769

Table 1 3. Results
Key concepts in scientometrics and in network analysis.
Term Explanation 3.1. References retrieved
Key concepts
Bibliometrics It enables researchers to see how pieces of evidence are We retrieved 28,381 unique publications in 21 different languages
connected, revealing the structure and development of a field (22,520 original articles, 4203 reviews, 174 editorials and 151 early
Systematic mapping It provides a snapshot of the current state of knowledge in the access articles) cumulating 588,626 citations, from 2307 different
scientific literature, identifying areas needing more research sources (Supplementary Fig 1). The first identified paper was published
attention and those ready for full synthesis
Intellectual structure It refers to a set of salient attributes of the knowledge base that
in 1963 by Zrull and colleagues on the comparison of chlordiazepoxide,
can provide an organized and holistic understanding of the D-amphetamine, and placebo in the treatment of the hyperkinetic syn­
chosen scientific domain drome in children (Zrull et al., 1963). The number of publications
Performance It quantifies citation impacts and productivity using several gradually increased from 10 to 147 articles per year in the 1990–1997
analysis metrics, such as publication-related metrics (total publication,
period, then exponentially increased from 264 to 2067 articles in the
number of co-authors.), citation-related metrics (total citation,
average citation), and citation and publication -related metrics 1999–2020, with an average growth rate of 11.12 % per year that
(g-index, number of cited papers.). continues (Supplementary Fig 2). The average citation per year grew
Collaboration They are defined as a set of individuals who come together and from 2.3 in 1990–4.7 in 2020. By way of comparison with other disor­
networks collaborate on particular tasks such as publishing a paper. ders, a search in PubMed showed an increase from 541 to 6577 hits for
Key metrics
Betweenness The algorithm calculates unweighted shortest paths between
(depression AND children) from 1990 to 2021, and from 587 to 3606
centrality all pairs of nodes in a graph. Each node receives a score, based hits for (asthma AND children) in the same time period.
on the number of shortest paths that pass through the node (
Brandes, 2004; Freeman, 1977).
Burstness analysis Citation burst is a detection of a burst event. (Kleinberg, 2003)
3.2. Analysis of co-citation reference: clusters of research and most cited
A citation burst provides evidence that a particular
publication is associated with a surge of citations.
papers
Furthermore, if a cluster contains numerous nodes with strong
citation bursts, then the cluster as a whole captures an active 3.2.1. The co-cited reference network
area of research, or an emerging trend. The co-cited reference network for the 1980–2022 time period, as
Modularity scores Modularity is a measure of the structure of a graph, measuring
per CiteSpace slicing, is shown in Fig. 1. The time map of this network is
the density of connections within a module. Graphs with a
high modularity score will have many connections within a also available as Fig. 2. Of note, the name of the author in black refers to
module but only few pointing outwards to other modules. Its the most cited author citing that cluster. For instance, the above means
value ranges from 0 to 1 (Newman, 2006). the psychopharmacology cluster has been cited by Ron Kessler. An
Silhouette scores Silhouette score is a metric used to calculate the goodness of a alternative graphic representation of the clusters is provided in Sup­
clustering technique (Rousseeuw, 1987). Its value ranges from
− 1 to 1.
plementary Fig 3. This network reflects the knowledge base combining
1: clusters are isolated from each other. research trends evolution, frontiers and highly cited papers. Detail of
0: clusters are indifferent, or we can say that the distance each cluster can be found in Supplementary Fig 4. Clusters labels
between clusters is not significant. detailed are presented in Supplementary Table 1.
-1: clusters are assigned in the wrong way.
Sigma scores This indicator measures the combined strength of structural
and temporal properties of a node, namely, its betweenness 3.2.1.1. Clusters of research: 1980–2022 time period. We identified 31
centrality and citation burst (Chen, 2006). different research clusters. Based on the largest connected component of
Centrality The centrality divergence metric measures the structural the network, four major research trends were uncovered. We present
divergence variation caused by an article a in terms of the divergence of
here the clusters contributing to these trends, with cluster number or­
the distribution of betweenness centrality CB(vi) of nodes vi in
the baseline network. The centrality divergence metric is dered by the largest (#0) to the smallest (#31). As shown in Figs. 1 and
potentially valuable for detecting boundary-spanning 2, the first trend was on ADHD treatment, risk factors and evidence
activities at interdisciplinary levels. synthesis (clusters #4, #1, #2, #0, 24, #13, #11, #31 and #27), the
Modularity The modularity of a network is a measure of the overall second on neurophysiology, neuropsychology and neuroimaging (clus­
divergence structure of the network. Its range is between − 1 and 1. The
modularity change rate of a scientific paper measures the
ters #18, #7, #3, #19 and #17), the third on genetics of ADHD (clusters
relative structural change due to the information from the #6, #8, #5), and the fourth on comorbidity (cluster #9, #12, #15 and
published paper with reference to a baseline network. #14). Two more recent and minor recent trends on exposure to envi­
ronmental toxins (clusters #29, #25 and #30) and Covid-19 (#23) were
also found. The emergence of a cluster on Covid-19 might be at first
likelihood ratio (P < 0.001), and were only modified when needed
surprising given that covid-19 related publications are limited to the
following the qualitative analysis to verify the adequacy of labels.
past 2 years. However, publications on Covid-19 tend to be highly cited.
In the networks, the frequency of occurrence is represented by the
For instance, Cortese et al. (2020) has been cited 163 times (28.6.22,
node size, and the thickness of the link between two nodes is propor­
Google scholar) despite being published only in 2020.
tional to it co-occurrence frequency. The networks timeline view also
For the first and largest trend on ADHD treatment-risks factors-evi­
permits to clearly identify the different research trends and its evolution.
dence synthesis, we report here the temporal evolution of the research
The g-index, a variant of the h-index which gives more weight to highly-
topic clusters, with indication of the cluster silhouette score (S), size (N),
cited articles, was used to obtain a better measure of citation perfor­
mean year (Y) of co-cited articles, and most representative reference.
mance (Egghe, 2006).
The first research cluster,#4, concerns diagnosis/tricyclic antidepres­
sants in the 80s, when efforts were ongoing in terms of the diagnostic
2.4. Sensitivity analyses
definition of ADHD alongside its treatment with this type of medication
class, (S = 0.976; N = 339; Y = 1989) (Biederman et al., 1991; Man­
To further explore the most recent research trends, we reduced the
nuzza et al., 1993) this cluster evolved into cluster #1, labeled ‘ADHD
time period to the last 5 years (2016–2022), and to 2021.
diagnosis and treatment’(S = 0.851; N = 409; Y = 1996) which
contributed to the foundation of ADHD diagnosis (Barkley, 2006) fol­
lowed by cluster #2 on ‘pharmacological treatment’ of ADHD (S =
0.875; N = 405; Y = 2006) (Pliszka, 2007), and a relatively isolated

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S. Cortese et al. Neuroscience and Biobehavioral Reviews 140 (2022) 104769

Fig. 1. Co-citation references network (1980–2022) with cluster visualization and burstness of hotspots obtained with CiteSpace. Note: Co-citation reference network
with cluster visualization and burstness of hotspots. The position of the node correspond to the year of publication. The size of a node (article) is proportional to the
number of times the node has been co-cited. Colored shades indicate the passage of the time, from past (purplish) to the present time (reddish). Colored tree rings
refer to the nodes with high betweenness centrality (external purple tree rings) and burstness (central red tree rings). (For interpretation of the references to colour in
this figure legend, the reader is referred to the web version of this article.)

Fig. 2. Visualization of the reference co-citation network time map (1980–2022) Note: In this time map visualization, for each cluster, nodes are organized by their
year of publication on horizontal lines. The 2019–2020 time frame permits to identify the latest most active co-cited clusters.

cluster #24, on ‘environmental risk factors’ (S = 0.999; N = 8; Y = them, or two clusters can become further separated with different
2008) (Banerjee et al., 2007). An important novel cluster of research has cluster labels.
progressively appeared this last decade on ‘evidence-synthesis’, cluster The second major research trend concerns neurophysiology, neuro­
#0 (S = 0.797; N = 434; Y = 2015) (Thomas et al., 2015), which is psychology and neuroimaging. This trend of research started around
currently the largest cluster. This cluster present ramification with 1999 with a cluster on electroencephalography, #18(S = 0.997; 18;
different other clusters: cluster #14 on ‘emotion dysregulation’(S = 1999) (Barry et al., 2003) it further evolved with another cluster on
0.982; 51; 2011) (Shaw et al., 2014), and different on-going clusters: ‘executive function theory’, #7(S = 0.909; 183; 2004) (Willcutt et al.,
‘psychoneuroimmunology’, #11(S = 0.947; 66; 2015) (Buske-­ 2005), then into the largest cluster of this trend on ‘neuroimaging’, #3(S
Kirschbaum et al., 2013), ‘nonpharmacological intervention’, #13(S = = 0.865; 347; 2009) (Cortese et al., 2012; Shaw et al., 2007), that
0.983; 64; 2012) (Sonuga-Barke et al., 2013), that is currently evolving developed two last clusters, one on ‘sluggish cognitive tempo’, #17(S =
into two emerging clusters (cluster #27(S = 0.999; 6; 2016), and #31(S 0.995; 19; 2013) (Becker et al., 2016) and finally one on-going cluster on
= 1; 4; 2012) (Cerrillo-Urbina et al., 2015) on ‘physical exercise’, two ‘default mode network’, #19(S = 0.992; 14; 2017) (Friedman and
separate clusters due to different co-citation dynamics. In general, two Rapoport, 2015).
distinct clusters may be formed with a variety of reasons such as per­ The third main trend concerns genetics of ADHD. It also started
sonal/subcommunity preferences or topic differences, but the labelling around 1999, with a cluster on genetic ‘polymorphism’, #6(S = 0.934;
words are top-ranked words found in papers that cited these clusters. 190; 1999) (Faraone et al., 2001), that continued with a cluster labeled
Different future developments could be particularly interesting: the two ‘genetics’ on evidence-synthesis, #8(S = 0.905; 171; 2006) (Polanczyk
clusters will merge as a single one if more and more papers cite both of et al., 2007) and a cluster on ‘polygenic risk score’/ genome-wide

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S. Cortese et al. Neuroscience and Biobehavioral Reviews 140 (2022) 104769

association studies, #5(S = 0.845; N = 279; Y = 2015) (GDGPGC, (Faraone et al., 2021); the Brikell and colleagues review on ADHD ge­
2013). Compared to other major trends, this trend is currently less active netic studies (Brikell et al., 2021); the Luderer and colleague review on
according to the correspondent time map, with no important burstness alcohol use disorders and ADHD (Luderer et al., 2021); the paper from
(please see Table 1 for its definition) activity these last years (Fig. 2). the ADHD European Guidelines Group on the management of ADHD
The fourth trend concerns ADHD comorbidity, and starts with a (Coghill et al., 2021); and the Zhang and colleagues study on the links
cluster on ‘bipolar disorders’, #9(S = 0.953; 91; 2000) (Leibenluft et al., between ADHD and Alzheimer disease (Zhang et al., 2021).
2003). Other partially independent cluster emerges around 2004 on
sleep and ADHD, #12(S = 0.988; 65; 2004) (Cortese et al., 2009), and 3.3. Network analysis of co-occurring keywords
2012 with ‘Tourette syndrome’, #15(S = 0.996; 33; 2012) (Hirschtritt
et al., 2015), that further evolved into the ‘emotion dysregulation’ Analysis of the most frequent keywords can inform on the trends of
cluster, #14(S = 0.982; 51; 2011) (Shaw et al., 2014). This last cluster research and the development of research frontiers over time. We
shares important proximity with the ‘evidence-synthesis’, cluster #0, extracted the co-occurring authors’ keyword network for two different
into which it merges. time period, 1990–2022 (Supplementary Fig 10) and 2016–2022
Finally, two more recent trends appeared. One trend is on exposure (Fig. 3). Both networks presented a significant modularity and silhouette
to environmental toxins: ‘polychlorinated biphenyls’, #29 (S = 0.998; 5; scores (Q = 0.3017, S = 0.6388 and Q = 0.3742, S = 0.6654 respec­
2011) (Eubig et al., 2010), ‘exposure’, #30(S = 0.998; 4; 2014) (Braun tively). The time period starts in 1990, which is the first year with broad
et al., 2014; Lyall et al., 2017), ‘perfluoroalkyl substances’, #25(S = 1; 7; inclusion of search terms in published articles.
2018) (Lien et al., 2016); and one trend on Covid-19, #23(S = 0.996; 9; In the 1990–2022 network, six clusters were identified, labeled as
2020) (Wang et al., 2021). follows: ‘prevalence’, ‘response inhibition’, ‘ADHD’, ‘double blind’,
To view on-going active clusters (#0, #3, #5, #11, #19, #23, #25, ‘alcohol’ and ‘attention deficit disorder’.
and #27), we reported the time map of this network (Fig. 2), that helps In the 2016–2022 network, seven clusters were identified: ‘fMRI’,
to highlight the duration of a cluster and temporal positions of landmark ‘substance use’, ‘pregnancy’, ‘double blind’, ‘disability’, ‘schizophrenia’,
publications. In addition, we produced a video on the link walkthrough ‘ADHD’ and ‘dopamine’. A detail of the cluster labels can be found in
between clusters based on burstness dynamic for co-cited reference Table S4.
network (1980–2022) in Supplementary Fig 5 and as a visual material
on Open Science Framework.(https://osf.io/cy4v2/?view_onlY =
efcc2c0a379c4fb1923c3620d89e6056). 3.4. Research performance

3.2.1.2. Clusters of research: focus on 2016–2022 and 2021 period. A 3.4.1. Publication outputs and major journals
focus on the last 6 years of research provides a more accurate snapshot of Two-hundred different journals were identified. The top five journals
the latest trends of research. We produced the co-citation reference with the highest number of publications were: Journal of Attention
network for the 2016–2022 (year slices) time period (Supplementary Fig Disorders (n = 1219), JAACAP (n = 840), Journal of Child and Adoles­
6, 7) and the year 2021 with monthly slices (Supplementary Fig 8, 9). cence Psychopharmacology (n = 638), European Child & Adolescent Psy­
The CiteSpace parameters can be found in Supplementary Information chiatry (n = 505), and PLOS One (n = 440) (Table 1 and Supplementary
1. Fig 11). In terms of number of publications, the Journal of Attention
The 2016–2022 network presented four active clusters that were not Disorders ranked before JAACAP only in the last 5 years (Supplementary
highlighted in the 1980–2022 network: a cluster on ‘late-onset ADHD’ Table 5).
based on cohort studies, #7(S = 0.805; 53; 2014) (Moffitt et al., 2015) in The co-cited journal network, which uses as unit the most co-cited
proximity to cluster #0, a cluster on ‘obesity’, #4(S = 0.767; 91; 2017) journals, reveals the macro-structure of scholarly disciplines through
(Cortese et al., 2016), in proximity to cluster #3, a cluster on ‘autism the macro level analysis of journal titles, can be found as Supplementary
spectrum disorder’, #8(S = 0.813; 91; 2016) (Jensen and Steinhausen, Fig 12. JAACAP was the journal with the highest number of citations of
2015) that reactivates the ‘comorbidity’ trend, and a cluster on ‘spor­ papers on ADHD, followed by the American Journal of Psychiatry, Bio­
t-related concussion’, #15(S = 0.992; 7; 2016) (Alosco et al., 2014; logical Psychiatry, Pediatrics, and JAMA Psychiatry (Table 2).
McCrory et al., 2017) extending the ‘physical exercise’ clusters.
Furthermore, when focusing on 2021, we identified two additional 3.4.2. Co-operation network across countries and institution
recent clusters on ‘functional connectivity’, #2(S = 0.851; 2013) The top five countries by number of articles and/or by number of
(Hoogman et al., 2017) and on ‘gut microbiota’, #6(S = 0.861; 82; citations were the USA (n = 11,768), the UK (n = 2732), Germany
2015) (Sharma and Couture, 2014). (n = 2303), Canada (n = 2072), and the Netherlands (n = 1789),
respectively.
3.2.2. Turning point papers When focusing on the 2016–2022 period, the only difference was a
We report the top ten cited references in Table 2. Most citations were progressive climb of China, presenting a clear burst in citations with a
from the largest trend on ADHD treatment, risks factors and evidence raise from the 8th to the 6th place (Table S5). The network of co-authors
synthesis, with meta-analysis and systematic reviews. After the meta- countries (1980–2022) is reported in Fig. 4. This network reveals
analysis by Polanczyk and colleagues (Polanczyk et al., 2007) on the important burst for China, Canada, Iran, Turkey and Brazil. In addition,
prevalence of ADHD, one of the most influential and turning point pa­ the burstness analysis confirmed that China and Poland presented the
pers is the Barkley’s handbook (2006) for ADHD diagnosis that is central latest citation burst (Table S2. A, B, C, D). We also produced the co-cited
to cluster #1. We reported in the supplement the burstness analysis institution networks for the 2016–2022 time period. The top five in­
(Supplementary Table 2), and conducted a structural variation analysis stitutions by number of affiliates were Harvard University (n = 1545),
for the 2021 network (Supplementary Table 3). The top five papers, with University of London (n = 1331), University of California (n = 1326),
the strongest modularity change rate (which measures the relative King’s College London (n = 928) and the Massachusetts General Hos­
structural change due to the information from the published paper with pital (n = 874). The University of California Irvine, New York Univer­
reference to a baseline network) (Chen, 2012) were: the Faraone et al., sity, and the National Institute of Mental Health were the most influent
2021, World Federation of ADHD International Consensus Statement institutions (Supplementary Table 5). The top five most cited in­
stitutions for last five years (2016–2022) were King’s College London,

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 Table 2

S. Cortese et al.
The top 10 most cited journals and references.
Top 10 journals of our author’s journal co-cited network
Journals with most articles Initial year Impact Total articles ( %) Total articles Journal H-index Journals with most citations Total
factor citations
(2019–2020)
1. Journal of Attention Disorders 1996 3.25 4.51 1219 72 1. Journal of the American Academy of Child and Adolescent Psychiatry 8165
2. Journal of the American Academy of Child 1987 8.82 3.10 840 243 2. American Journal of Psychiatry 7544
and Adolescent Psychiatry
3. Journal of Child & Adolescent 1994 2.57 2.36 638 84 3. Biological Psychiatry 6360
Psychopharmacology
4. European Child & Adolescent Psychiatry 1992 3.92 1.86 505 93 4. Pediatrics 6218
5. PLOS ONE 2006 3.24 1.62 440 332 5. JAMA Psychiatry 6016
6. Biological Psychiatry 1969 13.38 1.45 392 319 6. Journal of Child Psychology and Psychiatry 5481
7. Journal of Child Psychology and 1960 6.47 1.43 387 211 7. The Journal of Clinical Psychiatry 3909
Psychiatry
8. Psychiatry Research 1979 4.79 1.30 354 134 8. Journal of Attention Disorders 3820
9. Pediatrics 1948 7.12 1.23 334 345 9. The Lancet 3633
10. American Journal of Medical Genetics 1995 3.56 1.06 288 126 10. Psychological Medicine 3415
(part B)

Top 10 co-cited references of our reference co-cited network

Number of Number of Year Source Vol Pages Title Doi Type of paper Related
citations citations in cluster in
in the the Fig. 1
network literaturea

382 6233 2007 Am J Psychiatry 164 942–8

Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA. The 〈https://doi.org/10.1176/ajp.2007.164.6.942〉 Meta-analysis 7, 3, 24
worldwide prevalence of ADHD: a systematic review and metaregression
analysis.
6

367 1927 2006 Guilford Press – – Barkley RA. Attention-deficit hyperactivity disorder: A handbook for 〈https://doi.org/10.1177/1087054707305334〉 Diagnosis Handbook 1, 18
diagnosis and treatment, 3rd ed.
349 1299 2015 Pediatrics 135 994–1001 Thomas R, Sanders S, Doust J, Beller E, Glasziou P. Prevalence of 〈https://doi.org/10.1542/peds.2014-3482〉 Meta-analysis 0, 11
attention-deficit/hyperactivity disorder: a systematic review and meta-
analysis.
346 4291 2006 Am J Psychiatry 163 716–23 Kessler RC, Adler L, Barkley R, Biederman J, Conners CK, Demler O, 〈https://doi.org/10.1176/ajp.2006.163.4.716〉 Comparative study 2, 24
Faraone SV, Greenhill LL, Howes MJ, Secnik K, Spencer T, Ustun TB,
Walters EE, Zaslavsky AM. The prevalence and correlates of adult ADHD
in the United States: results from the National Comorbidity Survey
Replication.
346 3133 2005 Biol Psychiatry 57 1313–23 Faraone SV, Perlis RH, Doyle AE, Smoller JW, Goralnick JJ, Holmgren 〈https://doi.org/10.1016/j.biopsych.2004.11.024〉 Literature review 8

Neuroscience and Biobehavioral Reviews 140 (2022) 104769

MA, Sklar P. Molecular genetics of attention-deficit/hyperactivity
disorder.
278 1393 2014 Int J Epidemiol 43 434–42 Polanczyk GV, Willcutt EG, Salum GA, Kieling C, Rohde LA. ADHD 〈https://doi.org/10.1093/ije/dyt261〉 Systematic review/ 0
prevalence estimates across three decades: an updated systematic review meta-regression
and meta-regression analysis.
270 651 2015 Nat Rev Dis Primers 1 – Faraone SV, Asherson P, Banaschewski T, Biederman J, Buitelaar JK, 〈https://doi.org/10.1038/nrdp.2015.20〉 Literature review 0, 5, 11
Ramos-Quiroga JA, Rohde LA, Sonuga-Barke EJ, Tannock R, Franke B.
Attention-deficit/hyperactivity disorder.
262 1929 2012 Neurotherapeutics 9 490–9 Willcutt EG. The prevalence of DSM-IV attention-deficit/hyperactivity 〈https://doi.org/10.1007/s1331101201358〉 Meta-analysis 0
disorder: a meta-analytic review.
260 1245 2014 J Am Acad Child 53 34–46 Visser SN, Danielson ML, Bitsko RH, Holbrook JR, Kogan MD, Ghandour 〈https://doi.org/10.1016/j.jaac.2013.09.001〉 Systematic review 0
Adolesc Psychiatry RM, Perou R, Blumberg SJ. Trends in the parent-report of health care
provider-diagnosed and medicated attention-deficit/hyperactivity
disorder: United States, 2003–2011.
257 1201 2005 Lancet 366 237–48 Biederman J, Faraone SV. Attention-deficit hyperactivity disorder. 〈https://doi.org/10.1016/S0140-6736(05)66915-2〉 Literature review 0, 13

a
Number of citations in the literature according to the journal where the paper was published.
S. Cortese et al. Neuroscience and Biobehavioral Reviews 140 (2022) 104769

Fig. 3. Timeline visualization of co-occurring authors keywords network (2016–2022). Note: In this co-occurrence author’s keywords analysis, the size of the cross
are proportional to the frequency of keyword occurrence.

Fig. 4. Network of co-authors’ countries (1980–2022) Note: The network of co-authors countries permits to reveal the collaborative country network. Betweenness
centrality organize the network, with the countries presenting the most important centrality being at the center of the network. The position of the node corresponds
to the mean year of publication. The outermost purple ring denotes the centrality level, and highly central nodes are considered pivotal points in the research field.
We limited the nodes to the 60 first countries.

Karolinska Institute, Harvard Medical School, Radboud University Nij­ 4. Discussion

megen, and University of Toronto, and the institutions with the strongest
strength of citation burst were the University of Paris, Nanjing Medical 4.1. Identification of trends and future of evidence synthesis
University, Stockholm Health Care Services and, the Central South
University and University of Duisburg-Essen (Supplementary Table 2 E, To our knowledge, this study is the most comprehensive and detailed
F). Clusters of research collaboration revealed the relative paucity of scientometric analysis of the ADHD scientific literature. Scientometric
cooperation of the Turkish research network (Supplementary Fig 13). analysis propose a reproductive snapshot of the current state of
Finally, the analysis of co-authorship network can be found in Supple­ knowledge and highlights how evidence is connected, revealing the
mentary Fig 14 and Supplementary Table 6. structure and development of research on ADHD. Of note, some domains

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S. Cortese et al. Neuroscience and Biobehavioral Reviews 140 (2022) 104769

for which there may be a large body of publications might have not been concerns around side effects of medication and the lack of solid evidence
highlighted in our analysis if the related papers did not receive a high on their long-term effects (Cortese, 2019). Of note, current evidence
number of publications. shows that the role of non-pharmacological approaches for ADHD core
After initial descriptions of children with features reminiscent of symptoms, when considering blind raters of symptoms, is unclear
ADHD (e.g., a mischievous and uncontrollable ten-year-old boy by (Coghill et al., 2021). A conceptually related more novel cluster of
Haslam in Scotland – 1809 (Taylor, 2011), the German “fidgety Phil” by publications relates to the role of physical exercise as possible inter­
Hoffman in 1845 (Taylor, 2011), or the touch-à-tout (“touching every­ vention for ADHD, even if to date its actual impact in decreasing ADHD
thing”) boy by the French author Moreau - 1888) (Konofal, 2019), the core symptoms severity remains uncertain (Montalva-Valenzuela et al.,
first “scientific” account of an equivalent of ADHD is often considered to 2022). In the past two decades, the large body of publications on ADHD
be the one by George Frederick Still (the founder of pediatrics in En­ has fostered the publication of meta-analyses that now form a highly
gland, who described a syndrome phenomenologically similar to ADHD, cited body of research in the field and have contributed to inform clin­
that he labelled as a “deficit of moral control”), even though the focus of ical guidelines (Cortese, 2020), as well as provided important figures on
his work was on defects of moral control rather than inattention/hy­ the epidemiology of ADHD by pooling data from studies across the world
peractivity/impulsivity (Taylor, 2011). Afterwards, “modern” research (Polanczyk et al., 2007).
on ADHD took off in the 70s. Since then, ADHD has evolved as a complex Complementing genetic research, more recent investigation has been
and in part controversial entity, despite a large body of evidence, devoted to environmental risk factors, mainly biological ones. In
providing compelling answers to a series of questions on the disorder particular, there has been a focus on toxins/chemicals. Given a number
(Faraone et al., 2021). of methodological issues in currently available studies, the role of
The inspection of our co-citation reference network shows that in the chemicals, in particular pesticides, in the pathophysiology of ADHD
early phases of the “modern” literature, publications on ADHD were needs to be further elucidated (Tessari et al., 2022).
mainly focused on its diagnosis and pharmacological treatment. In fact, When zooming more closely on the past five years, interesting clus­
our first cluster, in chronological order, grouped citations on tricyclic ters emerged, including lines of research on: 1) the relationship between
antidepressants (alongside those on diagnosis) that were tested in the ADHD and autism, likely strengthened by the removal, by the DSM-5, of
80s as a possible treatment for ADHD, a long time after the report, by the veto of co-diagnosing AHD and autism; 2) the link between ADHD
Bradley in 1937, of positive effects of benzedrine sulfate, an amphet­ and obesity, reflecting the awareness of significant links between mental
amine compound, on ADHD symptoms (Strohl, 2011). Whereas there is and physical conditions (Cortese et al., 2020); 3) gut-microbiome, in line
currently meta-analytic evidence that tricyclic antidepressants are effi­ with a recent research trend across several areas in psychiatry (Cryan
cacious for ADHD symptoms (Otasowie et al., 2014), at least in the short and de Wit, 2019); 4) a controversial topic, i.e., the possible adult onset
term, such evidence is limited to a small number of RCTs (n = 5, desi­ of ADHD, which some researchers posit is accounted for by a late
pramine) and tricyclic antidepressants are not recommended in current manifestation symptoms that were present in childhood but were not
clinical guidelines for ADHD due to concerns around their possible impairing due to effective scaffolding (Riglin et al., 2022).
cardiovascular effects. Following these first lines of research, research Overall, our scientometric analysis shows that the bulk of the sci­
on ADHD addressed then its neurophysiological correlates (initially with entific literature on ADHD over the past decades has been driven by a
EGG given its availability across labs), genetics underpinnings (promp­ medical model, addressing the neurobiological correlates of the disor­
ted by findings of high heritability - around 70 %) (Faraone and Larsson, der. Arguably, this has been influenced by initial neurological formu­
2019), and relevant comorbidities/differential diagnoses, such as sleep lations of what can be considered as precursors of ADHD, namely
disorders and bipolar disorder. Comorbidities evolved later on into other minimal brain damage (Taylor, 2018). More distally in time, the notion
areas, such as Tourette, reinforcing the notion of ADHD as a neuro­ of constitutional deficit resonates with the idea, put forward after the
developmental disorder that was made official in the DSM-5. Subse­ industrial revolution, that children were not merely “economic units”
quently, an increasing focus, starting around 2010, has been on the for the family (workers) but human beings characterized by a develop­
dimensional constructs such as the role of emotional dysregulation that, mental process that could go awry (Taylor, 2018).
even if not currently conceptualized as a core feature of ADHD, many in Whereas the neurobiological bases of ADHD are undeniable, and are
the field deem an essential characteristic of individuals with ADHD, supported by a large body of evidence (Faraone et al., 2021), we think,
especially in adulthood (Lenzi et al., 2018; Shaw et al., 2014). in line with Hinshaw and Scheffler (Hinshaw and Scheffler, 2018), that
Furthermore, a large body of literature has focused on executive dys­ researchers in the field should avoid reductionist models of ADHD, and
functions, that have been conceptualised, for a while, to underlie ADHD focus on the role of cultural/contextual factors, alongside neurobiolog­
(Barkley, 1997). However, it is currently well established that the profile ical factors. Hinshaw and Scheffler (Hinshaw and Scheffler, 2018) posit
of executive dysfunctions is heterogeneous across individuals with that pressure for performance and productivity are key elicitors and
ADHD and some of them may present with no executive dysfunction at “revealers” of ADHD symptoms that have an undeniable neurobiological
all (Lambek et al., 2018). More recently, a sizeable portion of the neu­ basis, making ADHD at once a biological and cultural phenomenon. We
ropsychological literature has focused on the concept of sluggish cognitive look forward to seeing more research in this area. Relatedly, other
tempo, characterized by excessive daydreaming and slow processing of psychosocial topics of interest are stigma (only 20 hits, from a PubMed
information, which nosographic links with ADHD remain unclear and search on 6 June 2022 matching terms for ADHD and stigma in the title
are an active area of investigation (Becker, 2021). The availability of of the publication) and neurodiversity (only 1 hit), for which no large
neuroimaging approaches such as magnetic resonance imaging has clusters were detected.
fuelled another important line of research in ADHD starting in the 90s,
initially focused on the structural and then on the functional brain 4.2. Research networks
correlates. More recently, neuroimaging studies on ADHD have
addressed the role of the default-mode-network (DMN) following the The secondary objective of this study was to assess research perfor­
implementation of resting state MRI methods (Cortese et al., 2021), and mance from institutions, countries, and authors. We have provided a
the proposal of the DMN hypothesis of ADHD, i.e., that attentional lapses large amount of data that we deem will be helpful for the readers,
are causes by inappropriate activity of the DMN during task-based ac­ particularly those involved in research. While a detailed appraisal of
tivities (Sonuga-Barke and Castellanos, 2007). Likewise, genetic these data goes beyond the scope of this paper, we highlight here one
research has evolved including more advanced approaches, such as relevant finding. In contrast with the -hopefully now outdated-
polygenic risk scores. The past two decades have seen also an increasing misconception that ADHD is an “American condition”, it is interesting to
interest on non-pharmacological approaches for ADHD, possibly due to note that, while the USA ranked first in terms of number of articles and/

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S. Cortese et al. Neuroscience and Biobehavioral Reviews 140 (2022) 104769

or by number of citations, the two most cited institutions in the past five Disclosure
years were King’s College London and Karolinska Institute (Sweden),
and important bursts were found for China, Canada, Iran, Turkey and This research did not receive any specific grant from funding
Brazil. In line with Cortese and Coghill (2018), we look forward to agencies in the public, commercial, or not-for-profit sectors. Dr. Cortese.
seeing more research from less advantaged countries, to gain insight on has served on the advisory board of the Association for Child and
the interplay between neurobiological and socio-cultural factors in Adolescent Mental Health (ACAMH). He has received honoraria from
ADHD. ACAMH and the British Association for Psychopharmacology. He has
served as deputy editor of Evidence- Based Mental Health, associate
4.3. Limitations editor of Child and Adolescent Mental Health, and on the editorial
boards of the Journal of Child Psychology and Psychiatry and he Journal
Our findings should be considered in the light of some limitations. of Child and Adolescent Psychopharmacology, and CNS Drugs. Dr. Solmi
First, scientometric studies rely mostly on co-citations. This can be has been a consultant for/received honoraria from Angelini, Lundbeck,
problematic in particular with ‘citation distortion’, i.e., distortions in the Otsuka. Dr. Sabe, Dr. Chen, and Dr. Perroud declare no conflicts of
persuasive use of citations, that can be used to establish unfounded interest.
scientific claims as fact (Greenberg, 2009). Such bias can however be
detected with a detailed examination of hotspots. Second, we only Data Availability
searched WOSCC, which can limit the type of retrieved publication
(Singh et al., 2021; Visser et al., 2021). For most databases, such as Data will be made available on request.
PubMed or Embase, full references text and citations lists are not
available. The actual differences in references classifications between Appendix A. Supporting information
WOSCC and other sources such as Scopus may pose non-trivial chal­
lenges for merging references from different databases, which may Supplementary data associated with this article can be found in the
require a significant degree of manual interventions. The future devel­ online version at doi:10.1016/j.neubiorev.2022.104769.
opment of software could make it possible to simultaneously analyse
results from different databases with reliable automatic duplicate References
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