The Relationship Between Childhood and Adult Attention-Deficit–Hyperactivity Disorder and General Psychopathological Features in Individuals Who Apply for Bariatric Surgery

Abstract

Background:

The relationship between obesity and attention-deficit–hyperactivity disorder (ADHD) is shown in recent studies. In our study, we have analyzed the relationship between childhood and adulthood (ADHD) and general psychopathological features in morbidly obese individuals who have applied for bariatric surgery.

Methods:

One hundred seventy-seven morbidly obese patients (body mass index ≥40) who have been referred for bariatric surgery volunteered to participate in the study. The average age of the participants is 36.60 ± 8.46, and 143 of them are female and 34 are male. All volunteers filled the Wender Utah Rating Scale short version (WURS-25), Adult ADHD Self-Report Scale (ASRS-11), and Symptom Check List (SCL-90) tests.

Results:

The ADHD rate in morbidly obese individuals was 19.20%. Also, we found that in morbidly obese individuals who applied for bariatric surgery, adult and childhood ADHD were highly related to psychopathological (somatization, obsessive compulsive, interpersonal sensitivity, depression, anxiety, anger, hostility, phobic anxiety, paranoid thoughts, psychoticism, and additional symptoms) features. Psychopathological features in a statement that ADHD was evaluated in the morbidly obese individuals are an active factor.

Conclusions:

As a result of the findings of our study, we suggest paying attention to ADHD symptoms and psychopathological factors of morbidly obese individuals.

Introduction

Obesity is a serious health problem related to several social, environmental, neurological, and psychological factors.¹ In studies focused on obesity and psychiatric disorders, it has been shown that mood disorders,^2,3 anxiety disorders,^4,5 exposure to stress,^6,7 reward addiction behavior,⁸ and eating disorders⁹ highly accompany each other. Recently, studies showing a relationship between attention-deficit–hyperactivity disorder (ADHD) and obesity have been reported.^10,11

ADHD is a chronic neurodevelopmental disorder that starts in childhood and shows its effects in adulthood. ADHD is characterized by pervasive and impairing symptoms of inattention, hyperactivity, and impulsivity, according to DSM-IV.¹² According to DSM-IV criteria, ADHD frequency in children is reported as 6–7%.¹³ As a result of longitudinal follow-up of people during the adolescent and adult period who have an ADHD diagnosis in childhood, it was determined that ADHD diagnosis continues in nearly half of them.^14,15 Adult ADHD symptoms are usually: distractibility, depression, impulsivity, sensitivity to stress, discomfort, and behavior problems. In studies with public-wide samples, the adult ADHD rate has been reported to be 3.4% and 4.4%.^16,17 Patients with adult ADHD comorbidity mostly have depression, anxiety, substance use disorders, and eating disorders.^18,19

Obesity and ADHD are considered as two important diseases affecting the mental health of the people negatively, and they are related to each other.^20,21 Nearly half of the children who are hospitalized because of obesity also have an ADHD diagnosis.¹¹ Similarly, almost half of the children with ADHD are also overweight and obese.¹⁰ Also, ADHD diagnosis in children and adolescents is a critical risk factor for obesity and excessive weight gain during the transition period to adulthood.^22–24 According to population-based and large sample studies carried out in the USA and Germany on morbidly obese individuals, people with obesity have a high adult ADHD rate, and there is a significant positive relationship between ADHD and obesity.^25,26 In the study of Altfas on individuals applying for obesity treatment, it is reported that 27.4% of 215 patients with grade III obesity have adult ADHD.²⁷ It was found that 10% of 187 patients who applied for bariatric surgery have an adult ADHD diagnosis, and these individuals show a high level of depression and anxiety symptoms.²⁰ In a similar study, 12.1% of 116 patients were found to have adult ADHD.²⁸

The accompaniment of ADHD and obesity in individuals applying for bariatric surgery is reported as a significant risk factor in the postoperative period regarding weight loss and continuity of weight loss.²¹ Also, it is stated that a psychiatric diagnosis before surgery in patients applying for bariatric surgery decreases treatment success.^29,30 It has also been shown that anxiety and depressive symptoms decrease significantly with weight loss rate in patients applying for bariatric surgery.^31,32 Because of this, determination of a psychiatric diagnosis in patients applying for bariatric surgery and their interaction with each other has a significant role in the maintenance of weight loss and the success of the treatment.

ADHD is assessed as a neurodevelopmental disorder that starts in childhood and whose effect decreases in adulthood.¹⁴ Besides this, it is indicated that ADHD symptoms that continue in adulthood can be associated with several mental problems.^16,17 That is why we wanted to analyze the interaction of ADHD symptoms of the individuals who have applied for bariatric surgery with other psychopathological features other than depression and anxiety. At the same time, we wanted to compare the effect of childhood and adulthood ADHD symptoms that tends to decrease with age on the mental health in morbidly obese individuals.

In this study, the interaction of ADHD symptoms with mental problems other than depression and anxiety in morbidly obese individuals (body mass index [BMI]: ≥40 kg/m²) is analyzed. At the same time, the effect of childhood and adulthood ADHD symptoms on the general mental health in morbidly obese individuals is compared.

Methods

Participants and procedures

Our study involved morbidly obese patients who were referred from the Department of General Surgery of our institution to the bariatric surgery polyclinic of our hospital between 2013 and 2014. The study was based on voluntary participation. Two hundred morbidly obese patients were evaluated in our study, whose purpose of admission to the hospital was obesity surgery. The exclusion criteria of our study were: education less than 5 years and presence of any psychopathology of the patient that may preclude surgery. For this reason, six patients whose education level was less than 5 years and four patients showing determined psychopathological features (bipolar disorder = three patients, mental capacity at limit = one patient, schizophrenia = none) were excluded from the study. Due to the lack of a standardized education in our country regarding primary school graduation, and as the validity of the scales used in the study has been made of at least primary school graduates, at least, primary school graduates are included in the study. Besides this, DSM-4 criteria are used in the psychiatric evaluation of the participants. The publishing of DSM-5 book was made after the start of the study. That is why we have begun the study by using DSM-4 diagnostic criteria, but have continued with DSM-5. Besides this, the diagnostic criteria defined by exclusion criteria (schizophrenia, mental limitations, bipolar disorder) do not include any difference that can affect the study regarding DSM-4 and DSM-5.

At the same time, data of 13 patients with missing or wrong measurements were not included in the study. As a result of these criteria, the number of participants in our study was composed of 177 volunteer morbidly obese individuals. Our study is carried out by the Declaration of Helsinki.

Main outcome measures

Patients were evaluated by paper and pencil tests such as the Symptom Check List (SCL-90), Wender Utah Rating Scale (WURS-25), and Adult ADHD Self-Report Scale (ASRS-11).

Symptom Check List Revised (SCL-90-R)

Symptom Check List Revised is an assessment tool developed by DeRogatis that evaluates psychiatric symptoms and is composed of 90 articles and nine subscales. The validity and reliability of the scale have been established by Dag in our country and its coefficient of reliability according to subscales was determined as follows: somatization (S) 0.82; obsessive compulsive (O) 0.84; interpersonal sensitivity (IS) 0.79; depression (D) 0.78; anxiety (A).73; hostility (H) 0.79; phobic anxiety (PA) 0.78; paranoid ideation (PI) 0.63; psychoticism (PS) 0.73; and additional scale (AS) 0.77.^33,34 In addition to this, by using the 90 questions of the scale, Global Severity Index is calculated that measures the general psychopathological feature.

Wender Utah Rating Scale short version (WURS-25)

This scale has been developed to scan the childhood ADHD symptoms in adults retrospectively.³⁵ Childhood ADHD symptoms that the individuals have before age 18 are scanned with this scale. The validity of the scale was established by Oncü et al. in our country in 2005. This scale is a valid and reliable measuring tool that is composed of 25 questions graded between 0–4. The internal consistency coefficient of the Turkish version is 0.93, and the test–retest reliability is 0.81. The breakpoint of the scale was determined to be 36 in our country. It also classifies the group of patients with childhood ADHD correctly at a rate of 82.5% and the healthy control group as 90.8%. The scale has five subscales, including attention deficit, impulsiveness, irritability, depression, and school problems.³⁶

Adult ADHD Self-Report Scale (ASRS-11)

This scale was developed by the World Health Organization depending on DSM-IV ADHD diagnostic criteria to determine ADHD symptoms in adults.³⁷ The validity and reliability of its Turkish version were established by Dogan et al.³⁸ In the Turkish validity study of the scale, internal consistency coefficients for the whole scale and the subscales were in the range of 0.78–0.88, and the test–retest reliability coefficient was in the range of 0.73–0.89. A total of 18 questions in the scale are graded between 0–4, and they are intended to specify the frequency of each symptom in the last 6 months. Questions in the scale are composed of two subscales; nine questions evaluating inattention and the rest evaluating hyperactivity/impulsiveness symptoms.

Statistical analysis

To evaluate the data in our study, we have used Pearson correlation analysis, t-test for independent groups, and hierarchical regression analysis. Before the analysis, it was tested if data were normally distributed or not. As a result of these tests, it was evaluated that normality assumption was met for all analysis. The significance level for all analyses was set at p < 0.05, and the SPSS 22.0 program was used for analysis of the data.

Results

There were 143 female (80.79%) and 34 male (19.21%) participants. The average age of the participants was 36.60 ± 8.46. Sixty-three of the patients (35.59%) were primary school graduates, 30 (16.94%) were secondary school graduates, 57 were (32.20%) high school graduates, and 27 were (15.25%) college graduates. Marital status: 40 patients were single (22.59%), 123 patients were married (69.49%), and 14 were divorced (7.90%). Fifty-six (31.63%) of the participants declared that they had applied for psychiatric treatment in the past, and 26 (14.68%) claimed that their families had psychiatric treatment in the past. According to the WURS, it was determined that 34 patients (19.20%) had childhood ADHD.

According to Pearson correlation analysis results, it was found that there was a highly positive relation between the WURS, SCL-90 all psychopathology subscales, and general psychopathology at a level of p < 0.001. It was found that there was a high positive relationship between the ASRS, SCL-90 all psychopathology subscales, and general psychopathology at a level of p < 0.001 (Table 1).

Table 1.

Wender Utah Rating Scale, Adult ADHD Self-Report Scale and Symptom Check List-90 Analysis in Obese Patients Who were Admitted to Bariatric Surgery (Pearson Correlation Analysis Results)

	WURS	ASRS	HI	I	S	O	IS	D	A	H	PA	PI	PS	AS
ASRS	0.46^*	—
HI	0.40^*	0.87^*	—
I	0.42^*	0.88^*	0.56^*	—
S	0.31^*	0.43^*	0.41^*	0.36^*	—
O	0.48^*	0.63^*	0.51^*	0.61^*	0.64^*	—
IS	0.52^*	0.48^*	0.43^*	0.42^*	0.59^*	0.81^*	—
D	0.52^*	0.54^*	0.46^*	0.50^*	0.68^*	0.81^*	0.88^*	—
A	0.32^*	0.41^*	0.38^*	0.35^*	0.66^*	0.67^*	0.68^*	0.75^*	—
H	0.40^*	0.44^*	0.39^*	0.39^*	0.55^*	0.71^*	0.68^*	0.76^*	0.76^*	—
PA	0.30^*	0.36^*	0.26^**	0.37^*	0.53^*	0.65^*	0.64^*	0.68^*	0.67^*	0.63^*	—
PI	0.52^*	0.50^*	0.46^*	0.43^*	0.58^*	0.77^*	0.78^*	0.78^*	0.65^*	0.71^*	0.57^*	—
PS	0.50^*	0.45^*	0.40^*	0.40^*	0.59^*	0.71^*	0.78^*	0.79^*	0.72^*	0.72^*	0.70^*	0.76^*	—
AS	0.43^*	0.44^*	0.46^*	0.32^*	0.66^*	0.73^*	0.69^*	0.75^*	0.64^*	0.68^*	0.63^*	0.67^*	0.72^*
GSI	0.51^*	0.56^*	0.49^*	0.49^*	0.78^*	0.88^*	0.89^*	0.94^*	0.84^*	0.83^*	0.77^*	0.84^*	0.87^*	0.83^*

^*p < 0.001, ^**p < 0.01.

WURS-25, Wender Utah Rating Scale; ASRS, Adult ADHD Self-Report Scale; HI, ASRS hyperactivity/impulsivity; IN, ASRS inattention; S, somatization; O, obsessive compulsive; IS, interpersonal sensitivity; D, depression; A, anxiety; H, hostility; PA, phobic anxiety; PI, paranoid ideation; PS, psychoticism; AS, additional scale; GSI, Global Severity Index; ADHD, attention-deficit–hyperactivity disorder.

According to the results of independent group t-test done among the groups with and without childhood ADHD, it was found that ASRS (p < 0.001) and ASRS subscales (p < 0.001) scored averages; general psychopathology scored average (p < 0.001); SCL-90 subscale scored average, except the somatization subscale (p = 0.001) differed at a level of p < 0.001 (Table 2). As the cutoff point of the ASRS that we use in our study has not been determined in the validity test made in our country, the comparison of psychopathological features regarding adult ADHD symptoms could not be made. In addition to this, as nearly half of the childhood ADHD symptoms decrease in adulthood,¹⁵ WURS-25 (a diagnostic tool that helps diagnose retrospectively) scale was primarily preferred in the t-test.

Table 2.

Comparisons of Symptom Check List-90 and Adult Attention-Deficit–Hyperactivity Disorder Self-Report Scale Scores Between Patients With and Without Childhood Attention-Deficit–Hyperactivity Disorder

	ADHD (−) (n = 143)	ADHD(+) (n = 34)	F	T	p
ASRS	22.23 ± 8.31	32.48 ± 7.85	0.434	−6.427	<0.001
HI	12.20 ± 4.85	16.94 ± 4.14	1.273	−5.247	<0.001
I	10.03 ± 4.75	15.52 ± 5.10	0.390	−5.956	<0.001
S	1.12 ± 0.65	1.58 ± 0.86	8.506	−3.435	0.001
O	1.00 ± 0.67	1.83 ± 0.77	0.793	−6.227	<0.001
IS	1.13 ± 0.86	2.23 ± 0.87	0.293	−6.602	<0.001
D	0.94 ± 0.68	1.88 ± 0.89	3.889	−6.780	<0.001
A	0.64 ± 0.68	1.23 ± 0.86	6.012	−4.228	<0.001
H	0.69 ± 0.65	1.44 ± 1.00	12.388	−5.354	<0.001
PA	0.35 ± 0.44	0.86 ± 0.89	12.830	−4.833	<0.001
PI	0.84 ± 0.69	1.66 ± 0.76	0.855	−6.056	<0.001
PS	0.49 ± 0.48	1.13 ± 0.75	10.882	−6.110	<0.001
AS	1.15 ± 0.69	1.82 ± 0.67	0.315	−5.104	<0.001
GSI	0.85 ± 0.55	1.59 ± 0.69	1.462	−6.573	<0.001

According to the results of hierarchical regression analysis (Table 3), 24.5% of the scores related to general psychopathological features in morbidly obese model 1 were explained by subscale scores in ASRS (p < 0.001), and 31% of them were explained by ASRS inattentive (IN) and ASRS hyperactive/impulsive (HI) subscales (p < 0.001), respectively. In model 2, 15.1% of the general psychopathological scale scores of the morbidly obese were explained by WURS attention deficit (WURS-AD) scale scores (p < 0.001), and 20.5% of them were explained by WURS-AD and WURS impulsiveness (WURS-IMP) scale scores (p < 0.001), respectively, and 26.5% of them by WURS-AD, WURS-IMP, WURS-irritability (WURS-I), WURS depression (WURS-D), and WURS school problems (WURS-SP) scale scores (p < 0.001).

Table 3.

Global Severity Index of Patients (The Results of Hierarchical Regression Analysis)

	Unstandardized coefficients		Standardized Coefficients
	B	Standard error	Beta	t	p
Model 1
Step 1
(Constant)	0.320	0.100		3.193	<0.001
ASRS-IN	0.061	0.008	0.499	7.537	<0.001
Step 2
(Constant)	0.030	0.119		0.254	<0.001
ASRS-IN	0.040	0.009	0.322	4.212	<0.001
ASRS-HI	0.041	0.010	0.317	4.140	<0.001
Model 2
Step 1a
(Constant)	0.596	0.086		6.951	<0.001
WURS-AD	0.069	0.083	0.258	5.614	<0.001
Step 2a
(Constant)	0.562	0.083		6.727	<0.001
WURS-AD	0.045	0.014	0.258	3.311	0.001
WURS-IMP	0.055	0.016	0.278	3.563	<0.001
Step 3a
(Constant)	0.525	0.081		6.450	<0.001
WURS-AD	0.031	0.015	0.178	2.029	0.044
WURS-IMP	0.010	0.020	0.052	0.517	0.606
WURS-IR	0.034	0.011	0.282	2.977	0.003
WURS-D	0.027	0.018	0.166	1.470	0.144
WURS-SP	−0.022	0.021	−0.086	−1.071	0.286

Step 1: Variables entered in the first step: ASRS-IN; F = 6.627, df = 0.564, p < 0.001, adjusted R² = 0.245, R² change = 0.249.

Step 2: Variables entered in the second step: ASRS-HI; F = 5.391, df = 0.539, p < 0.001, adjusted R² = 0.310, R² change = 0.069.

Step 1a: Variables entered in the first step: WURS-AD; F = 31.518, df = 0.599, p < 0.001, adjusted R² = 0.151, R² change = 0.156.

Step 2a: Variables entered in the second step: WURS-IMP; F = 23.184, df = 0.579, p < 0.001, adjusted R² = 0.205, R² change = 0.059.

Step 3a: Variables entered in the third step: WURS-I, WURS-D, WURS-SP; F = 13.421, df = 0.557, p < 0.001, adjusted R² = 0.265, R² change = 0.072.

WURS-AD, attention deficit; WURS-IMP, impulsiveness; WURS-I, irritability; WURS-D, depression; WURS-SP, school problems.

Discussion

In our study, the childhood ADHD ratio in morbidly obese patients who apply for bariatric surgery was found to be 19.2%. The unexpected ADHD ratio found by Altfas in obese patients (27.4%) and the ADHD ratio in our study may be considered high concerning the average population.²⁷ The study of Altfas declared that this ratio was higher in grade III obese. In studies made on obesity patients, high comorbid ADHD rates compared with ADHD rates in the healthy population (3.4% and 4.4%) may be found since there is a consistent relationship between ADHD and obesity.^16,17 The high childhood ADHD rates determined in our study verifies the results of previous studies.

Similarly, it was reported that overweight and obesity prevalence in children and adolescents with ADHD is high, and childhood ADHD is an important factor in weight gain in adulthood.^22,39 At the same time, although there is not a significant difference in ADHD rates between children with and without obesity, it was determined that impulsivity, hyperactivity, and distractibility among those with obesity is higher than that of the controls without obesity.⁴⁰ Similarly, although there is not a significant difference in persistent, remitted, or lifetime ADHD rates among patients with and without obesity in adulthood, it was found that obese patients have a significantly higher level of ADHD symptoms in childhood.⁴¹

Despite the existence of consistent studies related to the accompaniment of obesity and ADHD, we have a limited level of knowledge to explain the relation between them. There are genetic and phenotypic hypotheses of keeping the BMI at an ideal level from childhood till adulthood, and IN and HI components of ADHD. In one study, it was stated that three or more IN and HI symptoms have a significant effect on the development of obesity from childhood to adulthood. It was reported that IN and HI may be behaviorally effective in weight gain in adolescence and in the continuity of weight gain in adulthood by respectively causing difficulty in maintaining attention (IN), and causing difficulty in inhibition of behavior (HI).²⁴ Inattention causes deterioration in executive functions. As people with IN have a tendency toward high-calorie food consumption, they consume fast food, and they stay a long time in front of the television and video games where weight gain is facilitated.^42–44 HI causes nutrition problems related to deficient inhibitory control. HI causes overconsumption, adaptation problems in diet planning, impulsive excesses, and high-calorie food consumption without a feeling of hunger.⁴⁵ We evaluated both childhood and adult ADHD symptoms in our study. As a result of the hierarchical linear regression analysis that we performed to predict obesity, we determined that adult ADHD symptoms are much more expository than childhood ADHD symptoms (Table 3). The HI component of adult ADHD parallels obesity with a rate of 31% (F = 5.391, p < 0.001, adjusted R² = 0.310) and the IN component with a rate of 24% (F = 6.627, p < 0.001, adjusted R² = 0.245). These results may show that both HI and IN symptoms of ADHD have an effect on obesity.

In neurobiological research related to obesity and ADHD, it was determined that there are similar consistent results related to dopamine and the reward system linked to dopamine.⁴⁶ The most important hypothesis in explaining the relationship between obesity and ADHD is the hypodopaminergic hypothesis. As a result of low tonic dopamine oscillation in the prefrontal zone, there are behaviors related to Reward Deficiency Syndrome. It is reported that to increase dopamine levels, obese individuals may present abnormal nutrition behavior (overconsumption, hedonic nutrition, binge eating, etc.) related to a self-medication hypothesis.^47,48 In some studies on eating addiction, it is stated that some highly palatable food may be addictive substances and overconsumption of these foods may be similar to addiction behavior.^49,50 It is reported that substance addiction and abuse rate is highly accompanied by ADHD. A behavior similar to addiction substance toward food in people with ADHD may cause obesity. Further studies could be done in this field.

Additional psychopathologies such as depressive disorder, anxiety disorder, and eating disorder are frequently reported among candidates who apply for bariatric surgery.^2,4,9,20 Our knowledge of whether these psychopathologies occur as a result of obesity is limited. Similarly, depression, anxiety, impulsivity, and substance use disorders are reported as comorbid in individuals with ADHD.^18–20

As a result of a comparison of general psychopathology subscale scores in our study between patients with and without childhood ADHD, we found that all SCL-90 subscale scores and general psychopathology scores were statistically significantly higher in patients with childhood ADHD than those without childhood ADHD (Table 2). Additionally, the psychopathology subscale scores showed a strong positive relation with the ADHD scale and subscales (Table 1). These results were also validated by correlation analysis. Our results showed that ADHD symptoms in candidates applying for bariatric surgery are closely related to general psychopathological deterioration, and the psychopathological score averages of the individuals with childhood ADHD are higher. Bariatric surgery implemented for obesity treatment is an effective treatment of medical events accompanying obesity.³⁰ Psychopathological features are important risk factors for the loss of weight and maintenance of weight loss following bariatric surgery.^21,51 In our study, we determined that the general psychopathological symptom rates were higher in patients with childhood ADHD compared with those without childhood ADHD. It may be useful to focus on ADHD, general psychopathological features during the follow-up, and treatment of these patients.

We found that adulthood ADHD scores explain 31% of general psychopathological features in obese individuals, and also childhood ADHD scores explain 26.5% of the general psychopathological features. The lower sensitivity of childhood ADHD scores than the adult ADHD scale in defining the psychopathology may be related to the fact that ADHD is a neurodevelopmental disorder and ADHD symptoms decrease at advanced ages.^14,37 According to hierarchical regression analysis results, in the two different models used to explain general psychopathology scores in individuals who apply for bariatric surgery, respectively, attention, hyperactivity–impulsivity and other ADHD features (irritability, depression, school problems) may be stated as effective factors. In many studies, it was determined that several psychiatric diseases accompany both obese individuals and individuals with adult ADHD.^2–4,18,19 As ADHD is an important risk factor in terms of weight gain,^23,24 at the same time as psychopathological features increase weight gain^5–7 and as ADHD and psychopathological features are highly related to each other,^52,53 ADHD should not be ignored in obese individuals while analyzing psychopathological features that are considered as important in the treatment of obesity.

The most important limitation of our study was the use of self-rating instruments in the study. There are several evaluation tools related to adult ADHD diagnosis.⁵⁴ We used the ASRS in our study, which is frequently used for adult ADHD and is preferred in prevalence studies.³⁷ Although sensitivity and specificity ratios for this scale were reported as 68–99%, inconsistent information may have been given as a result of subjective prejudices.³⁷ We have used the retrospective WURS scale for childhood.³⁵ As both current status and historical information were filled in as self-report, this may have caused inconsistent information. Another limitation of our study is the shortfall in the number of patients involved in the study. The fact that the individuals participating in the study were bariatric surgery candidates forms a homogeneous clinical population. The data of this study may not represent individuals who apply for nonsurgical treatment of obesity and obese individuals in public samples. For this reason, comparison of obese individuals with similar age and education levels and individuals who apply for bariatric surgery may give more useful results.

Conclusions

In our study, it is found out that, childhood and adulthood ADHD symptoms in patients who apply for bariatric surgery is in a high level related to the normal population. Moreover, significant correlations are found between general psychopathological features and ADHD symptoms. In our study, we have identified that IN and HI components continue from childhood into adulthood. Continuity of these features until adulthood may be related to losing control in weight gain and difficulty in the maintenance of weight. Evaluation of ADHD and psychopathologies before bariatric surgery may be useful in the postoperative care of these patients and prevention of regaining of weight.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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