Resiliência e TDAH: o que há de novo?

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1 Metropolitan Union for the Development of Education and Culture, UNIME, Brazil. 
2UNIME - Metropolitan Union for the Development of Education and Culture, Federal University of Bahia (UFBA), Federal 
Government Economy Ministry, Brazil. 
*Corresponding author: E-mail: calsilvia5@gmail.com; 
 
 
Chapter 1 
Print ISBN: 978-93-90768-37-0, eBook ISBN: 978-93-90768-38-7 
 
 
 
Resilience and ADHD: What is New? 
 
J. V. C. Freire1, R. A. Cerqueira1, D. F. Sousa1, J. F. A. Novaes1, T. M. Farias2 
and S. F. M. Cal1* 
 
DOI: 10.9734/bpi/rtcms/v9/7765D 
 
 
ABSTRACT 
 
ADHD (Attention-Deficit Hyperactivity Disorder) is a neurodevelopmental disorder, characterized by 
inattentive, impulsive or hyperactive behaviors that are manifested in a disproportional manner, 
considering the age and level of development of the individual. Resilience (RS) is a construct 
understood as being a dynamic process of positive adaptation within the context of great adversity. 
Studies about RS in ADHD may provide new therapeutic strategies. The aim of this study was to 
conduct an integrative review of the literature with the purpose of seeking to understand the aspects 
of RS and ADHD that have been studied over the last few years, as well as which advancements and 
new approaches have been made with regard to management of the disability. An integrative review 
of the literature was made in the databases of PubMed, SciELO, Lilacs and PsycINFO with the 
descriptors “TDAH e RESILIÊNCIA” and “ADHD AND RESILIENCE”. The articles included were those 
published in scientific journals over the last 20 years, written in the Portuguese, English or Spanish 
language, and within the age-range of the sample of up to 18 years. The review studies were 
excluded. In total 119 articles were identified, and after triage, 57 eligible articles remained. After 
application of the inclusion and exclusion criteria, the abstracts of the studies identified and removal of 
the duplicated studies, 09 studies were included and revised, of which 08 had a quantitative and 01 a 
qualitative approach. The articles pointed out strong relations between ADHD and low levels of RS, 
with increase in negative outcomes in adolescence, such as academic failure, lower self-esteem and 
development of anxiety and depression disorders. In a similar manner family members of individuals 
with ADHD also have more propensity to developing anxiety and depression disorders, which may be 
explained by the fact they share endophenotypes and by their exposure to similar factors that induce 
RS, such as family conflicts and adversities. 
 
Keywords: Resilience; ADHD; integrative review; neurodevelopmental disorder; social support. 
 
1. INTRODUCTION 
 
ADHD (Attention-Deficit Hyperactivity Disorder) is a neurodevelopmental disorder, characterized by 
inattentive, impulsive or hyperactive behaviors that are manifested in a disproportional manner, 
considering the age and level of development of the individual. The majority of diagnoses of ADHD 
are made in children of school going age, and according to The Diagnostic and Statistical Manual of 
Mental Disorders - DSM-5, require the presentation of symptoms in different environments, before 
the age of 12 years [1] and it is the most common neurodevelopmental disorder described in the 
DSM-V [2]. 
 
A relatively high prevalence of approximately 5% of the world child population has been observed [3], 
(Sayal, 2017; Yong et al. 2020), and 30 to 70% of these children maintain symptoms throughout their 
lifetime [4], exhibiting a prevalence of 2.5% in adults [4] and 2.5% in elderly persons (Michielsen, 
2012). 
 
 
 
 
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Whereas the prevalence in Europe was 7.2% (CI 95% 6.7 to 7.8), with lower estimates than those of 
North America, however, with few studies using random population sampling, suggesting that the 
prevalence of ADHD in the community (between 2.2% and 7.2%) reflects the variation in the 
methodology of studies (Sayal et al. 2017). 
 
Relative to gender, the male gender has higher probability of being diagnosed with ADHD than the 
female gender. In the National Health Interview Survey (NHIS) of 2011, of the U.S. Department of 
Health and Human Services of the Centers for Disease Control and Prevention, the estimated 
prevalence of ADHD in the male sex was 12 per cent; in contrast with the female sex that was 4.7% 
(Perou et al. 2013). 
 
With regard to the physiopathology, there is a body of evidence that ADHD is related to dysregulation 
of the dopamine system. The reward system is the neuropsychological mechanism that links 
dopamine to disorders that also show changes in the dopamine levels. However, the relations between 
the reward system, ADHD and its comorbidities have not yet been well established (Bădescu et al 
2016). According to Song et al. (2020), although ADHD is a heterogeneous disturbance, without a 
completely elucidated pathogenesis, studies in animal models have suggested the involvement of 
dopaminergic, noradrenergic and serotoninergic neurotransmission, with structural and functional 
abnormalities in the cortical and subcortical regions of the brain. 
 
ADHD has great impact on the lives of children affected by it and their families, as well as on the use 
of health services, specialized education, social assistance and criminal justice. Moreover, it has 
impact on mental health and the parents’ employment, family expenses, as well as crime and 
delinquency. A review of the literature conducted in the United States, about the costs related to 
ADHD estimated that these could range from US $ 143 billion to US $ 266 billion (Sayal et al. 2017). 
 
The impacts on persons affected are substantial, and are capable of leading to low performance at 
school [5] that could persist into adulthood [5], with psychosocial compromise at the young adult age, 
in addition to the increased risk for developing comorbidities, including depression and anxiety, 
learning disorders [6,7,8], binge eating disorder with consumption of low quality foods, capable of 
developing into obesity, dependence on the Internet and electronic media, substance abuse 
disorders, sleep disorders, behavioral disorders in childhood and anti-social personality traits [9]. 
 
Due to its implications, the disorder is considered a public health problem by the American 
Psychiatric Association, [10]. 
 
With regard to its etiology, there is still no consensus, however, the scientific literature has indicated 
that it concerns a heterogeneous syndrome involving genetic factors, such as inheritance of around 
76% [11,12,1], neurobiological factors, associated with multiple genes and environmental factors such 
as prenatal events (exposure to tobacco, alcohol, drugs, environmental toxins, complications during 
gestation or birth, prematurity and low birth weight), and in the early post–natal period (neonatal 
anoxia, convulsions, cerebral lesions and exposure to lead and polychlorinated biphenyls) [13,14,15, 
16]. 
 
Further to etiology, according to Weissenberger et al. [9], the environmental agents may be due to the 
mother’s exposure to: substance abuse, mainly nicotine and alcohol, endocrinological dysregulation, 
use of acetaminophen, unhealthy dietary habits, stress, low socioeconomic and educational 
condition, stressful family environment. After birth, the following could be risks: Passive (tobacco) 
smoking, contamination with substances (phthalates present in plastic toys and cosmetics; bisphenol, 
present in food packaging), stress, dysfunctional family, unhealthy dietary habits (rich in sugar and 
fats), social privation, negligence relative to care, negative influence of peers and authority figures, 
and a harmful lifestyle. According to Luo et al. [1], there are other factors associated with ADHD such 
as: prematurity,low birth weight, cranial trauma, exposure to organophosphorus [insecticides] (OP), 
polychlorinated biphenyls (PCBs) and lead. Moreover, Song at al. (2020) added: severe or hostile 
education. 
 
 
 
 
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Children, adolescents and adults with ADHD are subject to having problems such as: low self-esteem, 
family conflicts, problems of relationships between partners and married couples (Bierdman et al 
2012, Valqueizo- Madrid 2005), [17] to, when they are adults, greater probability of having automobile 
accidents, risky sexual practices, use of illicit substances, anti -social behavior, impaired social 
cognition [18,19,16,20] and sleep disorders (Cortese et al., 2009). 
 
Evidences have demonstrated that individuals diagnosed with ADHD are a highly heterogeneous 
group relative to their manifestations and results in the long term [1]. 
 
As regards treatment, according to the Guidance for identification and treatment of individuals with 
ADHD and autism spectrum disorder in England, in children, behavioral observation and 
psychological intervention are the first lines of treatment, and must precede pharmacological 
intervention. If the psychological/environmental interventions fail, medication of ADHD may be useful 
in the treatment of symptoms of inattention, hyperactivity, impulsiveness, aggression, irritability and 
emotional instability. Adults generally receive prescribed medications before psychological treatment 
[21]. 
 
There is still no curative treatment for ADHD, and the most frequently described medications are: 
Methylphenidate, Amphetamines and non stimulant drugs. In addition to pharmacological therapy, 
behavioral therapy, social skills, management of training, physical exercise, and nutrition have also 
been implemented in practice, however, there is wide variation in patients’ responses. Various factors 
contribute to the quantity of dopamine released by the neurons, and consequently, to the 
heterogeneity of the response [1]. Given the high rates of comorbidity associated with ADHD, 
other drugs must be considered for treating comorbidities such as anxiety, mood and sleep 
disorders [22]. 
 
Relative to the adverse effects of medication treatment, the use of amphetamines has been 
associated with a higher risk for psychosis than the use of methylphenidate (Moran at al., 
2019). Contrary to the concerns in clinical practice, there has been no evidence that the 
beginning of treatment with methylphenidate increased the risk for psychotic events in 
adolescents and young adults, including those who have a history of psychosis (Hollis et al. 2019). 
However, methylphenidate may cause: depression, compulsion and loss of appetite (Song et al. 
2020). 
 
Resilience (RS) is a construct understood as being a dynamic process of positive adaptation within 
the context of great adversity, and has the potential to provide more positive messages and a more 
balanced approach [to challenges? [23,24,25]. In this sense, individuals deal with events and risks 
within the context of their personal characteristics, family, social and cultural history [26]. Among 
the psychosocial risk factors (poverty, maltreatment, traumatic events etc.) and non–psychosocial 
factors (maternal injury, diseases, etc.), are some of the reasons/occurrences that increase the 
probability of poor adaptive results [25]. 
 
RS has been referred to as the capacity to resist and recover from the stressful challenges of life, or 
to adapt in a positive manner to the events and risks posed to development or health [27,28]. In the 
face of a factor of risk, the reactions may differ significantly, which is due to the dynamic aspect of RS 
[29,30], or the existence of protective factors that are defined by personal characteristics, those of the 
family and environment, which reduce the negative effect of adversities in a future outcome [31]. 
Relative to ADHD, RS may emerge from an appropriate adjustment between the individuals’ skills and 
the demands of their environment, or compensatory skills that substitute the shortcomings /deficits 
[32]. 
 
Studies about RS in ADHD may provide new strategies for treatment, as ADHD usually happens to 
be a comorbidity with other clinical conditions that also harm RS, it is necessary to gain a better 
understanding of how ADHD affects the levels of RS [33,7,8]. 
 
Research conducted in the field of RS has suggested that children are influenced by factors at 
different levels, starting from their personal profile of strong and weak points, through to factors in the 
 
 
 
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family, neighborhood, school and society . Evidences have suggested that the risk factors for rejection 
by peers in childhood and ADHD - alone or together - predict the wide range of future 
problems of adjustment [7]. In this sense, both the rejection of colleagues and ADHD in childhood 
would positively predict a wide range of negative results of adolescents. Rejection by peers was also 
identified as a factor of significant risk for an inadequate adjustment in typical populations and in 
ADHD [23,6]. 
 
The study showed that Group ADHD was less resilient than the Control Group (p <0.01). Group 
ADHD was composed mainly of men (83.3%), but there was no difference between the sexes with 
regard to the RS scores. Furthermore, the Group with ADHD had higher anxiety scores [33]. In the 
same sense, adolescents with ADHD exhibited lower levels of RS in comparison with sibling and TDA 
(adolescents with typical development), even when controlled for levels of anxiety and depression, 
which were higher in ADHD [25]. 
 
They pointed out some factors that may increase the chances of healthy social functioning: 
involvement of the parents, amplitude and intensity of the youngsters’ activity and social acceptance 
[34]. Social support is one of the factors of protection most frequently cited in the field of RS. The 
parental support perceived appeared to be more predictive of a wide range of results of adjustment in 
children, with the support of colleagues also affection the results of emotional well being. Moreover, 
the support perceived of teachers may be more specifically related to the results of functioning of the 
school [6]. 
 
RS has the potential to provide more positive messages and a more balanced capacity for 
adapting to this context [6]. Although it is recognized that all individuals, irrespective of the 
presence or not of a deficiency, may demonstrate some variability in their adjustment to some 
domains, many children at risk continue to demonstrate adaptation and positive RS over the course 
of time [7]. 
 
The aim of this study was to conduct an integrative review of the literature with the purpose of seeking 
to understand the aspects of RS and ADHD that have been studied over the last few years, as well as 
which advancements and new approaches have been made with regard to management of the 
disability. 
 
2. METHODOLOGY 
 
An integrative review of the literature was made in the databases of PubMed, SciELO, Lilacs and 
PsycINFO in September 2019, in which the search was carried out by four independent reviewers, 
who used the descriptors “TDAH e RESILIÊNCIA” and “ADHD AND RESILIENCE”. The articles 
included were published in scientific journals over the last 20 years (between February 1999 and 
February 2019), which complied with the following inclusion criteria: (01) Articles written in the 
Portuguese, English or Spanish language; (02) Articles that approached the relations between ADHD 
and Resilience; and (03) Article with samples in the age-range of up to 18 years. Furthermore, 
review studies were excluded. 
 
The PRISMA [35] recommendation was used in order toguide the stages of this review [35]. In total 
119 articles were identified, and after triage, 57 eligible articles remained. The triage, which consisted 
of application of the inclusion and exclusion criteria to the abstracts of the studies identified, and the 
removal of duplicated studies, was performed by one reviewer and checked by the other. Thus, 09 
studies were included and reviewed, of which 08 had a quantitative approach and 01, a qualitative 
approach. An additional search was also performed in the lists of references of the articles included, 
with the purpose of adding articles that eventually might not have been found in the previous stages 
of selection (Fig. 1). 
 
 
 
 
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Fig. 1. PRISMA flow diagram 
 
 
3. RESULTS 
 
The results of the integrative review are presented in the table below. 
 
 
 
 
 
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Table 1. Results of integrative review of the literature 
 
 Author/Year Design: N Results Conclusions 
1 REGALLA, MA. 
GUILHERME P; AGUILERA 
P; SERRA- PINHEIRO MA; 
MATTOS, P. [33] 
(Regalla et al., [33]) 
Case- control 24 Significant Correlations: 
 
= Depressive symptoms in the mothers and symptoms of 
anxiety in the children of Group ADHD. 
- Trait of anxiety and depressive symptoms in the mothers 
of Group ADHD. 
=Hyperactivity and symptoms of impulsiveness and 
negligence in the mothers of Group ADHD. 
Positive correlation between ADHD and 
low RS in adolescence. Control 
adolescents were more resilient compared 
with Group ADHD, in spite of having a 
lower IQ and lower socioeconomic status. 
Group ADHD > anxiety scores. ADHD is 
a risk factor for low levels of RS. 
2 LEE, S, SIBLEY MH; 
EPSTEIN J N.(2016). 
(Lee et al., [32]) 
Qualitative 
 
Study 
- Favorable outcome of youngsters with ADHD have been 
evaluated in a simplistic manner due to the absence of 
great negative events in the adult phase, such as the 
psychopathological type. 
RS may emerge from an appropriate 
adjustment between the individuals’ skills 
and the demands of their environment, or 
compensatory skills that substitute the 
shortcomings/deficits. However, additional 
empirical and theoretical studies are 
required for defining resilient outcomes 
by means of multiple domains, and in 
order to understand the factors and 
processes that contribute to RS, in spite 
of the persistent neurocognitive 
dysfunctions. 
3 RAY AR; EVANS SW; 
JANGBERG, JM (2017). 
(Ray et al., [34]) 
Transverse 324 Factors leading to > chances of youngsters with ADHD 
achieving health social functioning: involvement of 
parents, extension of youngsters’ activities and social 
acceptance. 
Consistent data about the importance of 
participating in sports and leisure activities 
so that patients with ADHD will be socially 
healthy in the presence of risk factors for 
social dysfunction. 
4 NIGG J; NIKOLAS M; 
FRIDERICI K; PARK L; 
ZUCKER R A. (2007).(Nigg, 
Nikolas, Friderici, Park, & 
Zucker, [36]) 
Case- control 543 Biological characteristics provide protection for children 
expose to moderate or high level family adversities. 
These children have protective genotypes, strong 
response inhibition or both. 
When children facing adversities are 
resilient, they seem to be protected from 
developing ADHD or behavioral disorders 
by means of two neurobiological 
mechanisms: 1- genotype of 
Catecholamine security. 2- inhibition of 
the effective and efficient response 
 
 
 
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 Author/Year Design: N Results Conclusions 
5 MIKAMI AY; HINSHAW, S P. 
2006 
(Mikami & Hinshaw, [23]) 
Prospective 
Cohort Study 
209 Presence of protective factors (self- competence at 
school, engagement in games with goals and popularity 
with adults) < girls with ADHD, who exhibit more 
negative outcomes during adolescence. 
ADHD and rejection by peers in childhood 
predict negative outcomes in 
adolescence, such as externalizing 
behaviors, failures at school, dietary 
disorders and substance abuse, however, 
no interactions were seen between these 
two factors in the production of these 
outcomes. 
6 MASTORAS, SM. et al. 
2018. (Mastoras et al., 
[6]) 
Prospective 
 
Cohort 
 
Study 
50 Children with ADHD < social support than the control 
group. No relations were found between the lack of 
support groups and the development of depression and 
anxiety, but the presence of these factors helped in the 
development of a sense of self value, success at school 
and in social acceptance. 
Evident differences between individuals 
with ADHD and those of the control group 
with regard to the social support indexes; 
when this factor was present, it induced 
positive outcomes in adolescence. 
7 MCCRIMMON A W; CLIMIE, 
E A.; HUYNH S. 2017. 
(McCrimmon et al., [7]) 
Transverse 54 Children with typical development did not differ from the 
children in the clinical sample (ADHD and autism 
spectrum disorder), as far as the trait of emotional 
intelligence or the factors of RS were concerned. 
The ability of children with ADHD to 
interact with others reduces a factor of risk 
for RS, in which self- knowledge of their 
emotions contribute to their self-efficacy 
and feelings of competence. 
8 SCHEI J et al. 2015 
(Schei et al., [8]) 
Transverse 717 Adolescents with ADHD who have low self-esteem and 
little capacity for organization, exhibit more severe 
deficiencies with regard to psychosocial functioning, in 
addition to having > risk for developing depression and 
anxiety disorders. 
High self=esteem during the three-year 
period of follow-up was a predictor of 
enhanced psychosocial functioning and > 
capacity for planning and with social 
competence. 
9 REGALLA, M. AR. et al. 
2019. 
(Regalla et al., [25]) 
Transverse 11 Individuals with ADHD > results in the Child Depression 
Inventory (CDI) and Children State-Trait Anxiety 
Inventory (CSTAI) when compared with the Group of 
adolescents with typical development. The qualitative 
measurement of RS by the Resilience Scale identified < 
values for the population with ADHD. 
ADHD was associated with low RS 
indexes and > development of depression 
and anxiety disorders, which was shared 
by the siblings of these individuals. These 
results may be related to both shared 
genetic factors and environmental 
factors within the family context. 
 
 
 
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4. DISCUSSION 
 
Identifying the relations between ADHD and RS, as well as the factors that contribute to optimizing 
them, may contribute to broadening the contemporary treatment options, not only the 
pharmacological, but the non pharmacological types as well, such as, for example, psychotherapy 
and changes in lifestyle, including the social connections. 
 
Factors such as physical exercise [34], leisure [34], environmental demands [32], involvement of 
parents [34], self- competence at school [23], engagement in games [23], social support [6], 
popularity [6], self-knowledge [7] and self-esteem [8], were cited in the articles researched in this 
study, as possible factors either related to the development of ADHD, or not, which resulted in a low 
or high level of resilience stemming from these factors. 
 
The trial was conducted by Regalla et al., [25] who showed evidence of a strong correlation between 
ADHD and low RS in adolescence. The Control Adolescent were shown to be more resilient when 
compared with Group ADHD. This could be explained by a variety of factors: parents of children 
with ADHD might be more critical, less rewarding and less responsible with regard to the ir children 
when compared with the Control Parents. Furthermore, children with ADHD exhibited more symptoms 
of impulsiveness,aggressiveness and adverse social behavioral patterns, which generally lead to 
them having problems with social interactions. The studies showed that individuals belonging to this 
group could be less popular and have fewer friends than the Control Individuals [37]. 
 
Youngsters with ADHD had deficits in the domains of social functioning. Approximately 80% of 
children with this disorder experience high rates of rejection by their peers. Where social skills were 
concerned, this group showed inability to share, cooperate and be in alternate shifts or groups. 
Although they engaged and were interested in social interactions with peers of their own age, the 
children with ADHD tended to be more intrusive and disruptive during their interactions. Moreover, 
they also exhibited difficulties with decoding social pathways, identifying problems and generating 
responses to problem solving tasks [38]. 
 
Social dysfunction is one of the most debilitating aspects of ADHD (Nijmeijer et al 2008). Taking this 
into consideration, makes it important do conduct researches with a view to improving the social 
functioning of these individuals. In a cross-sectional study conducted by Ray, Evans and Langberg 
(2016), some of the factors increased the chances of patients with ADHD achieving healthy social 
functioning: involvement of parents, extension of youngsters’ activities, intensity of activity and social 
acceptance. 
 
With further reference to social questions, the studies showed evidence of difference between 
individuals with ADHD and Control individuals, with regard to the indexes of social support; a factor, 
when present, which induced positive outcomes in adolescence. According to Mastoras, 
Saklofske, Schwean and Climie [6], there were significant positive associations between social 
support and sense self-concept, self-worth, self-confidence measures, and specific perceptions of 
competence at school and social acceptance of youngsters with ADHD. Support related to the parents 
and classmates are more extensively and strongly associated with the positive outcomes cited. 
 
Emerging evidences have suggested that ADHD may also be associated with deficits in the theory of 
mind (capacity to understand the states of mind) and recognition of emotion. Nevertheless, there were 
inconsistent results, and it is arguable if these deficits persist beyond childhood [2]. 
 
As regards age, according to SCHEI et al. [8], a cross-sectional study with 717 participants aged 
from 13 to 18 years, demonstrated that youngsters diagnosed with ADHD had a lower level of 
psychosocial functioning associated with low self-esteem, in addition to manifesting higher risk for the 
development of depression and anxiety disorders when compared with the Group of individuals with 
typical development, with the latter outcome being found more frequently in individuals with 
diminished perception of social competence. This association could result from the impact of the 
symptoms of ADHD on the formation of self- image and self=efficacy (conviction of having the 
 
 
 
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capacity to perform a certain task), indicating that failure of and negative experiences about individual 
skills frequently occur in this group of individuals. 
 
Evaluation of depression and anxiety disorders in adolescents with ADHD, when compared with their 
siblings and with youngsters that have typical development, indicated that ADHD is directly involved 
in the development of these conditions, because there were no significant socioeconomics 
differences between the above=mentioned groups. This impact also affected the siblings of 
individuals with the disorder, a situation that could be interpreted from two different perspectives; the 
first related to the influence of shared endophenotypes in one and the same generation, and the 
development of lower indexes of resilience. The latter quality could be associated with the exposure of 
subjects to determinant non genetic factors for the above-mentioned outcome, such as higher 
incidence of conflicts and low level of family support [25]. 
 
As non medication intervention, capable of improving the quality of life of patients with ADHD, other 
than psychotherapy [39], mindfulness meditation has been studied for the purpose of improving the 
ADHD symptoms, with success [40], both for children and adolescents and for their family members 
[41]. Positive results have also been found with transcendental meditation [42], however, for Evans 
et al. (2017) no conclusive result was found [43]. 
 
With further reference to non medication intervention, considering that different aspects of lifestyle 
have been shown to be related to ADHD, as was shown in this review, it is important to study this 
relationship. Lifetime habits such as low quality diet, physical inactivity, psychological stress, and 
exposure to environmental toxins are factors related to chronic systemic inflammation (Furnan et al. 
2019). 
 
A chronic, low level inflammatory response may cause a breakdown in the immunological tolerance, 
and lead to extensive changes in all the tissues and organs, for example, the brain. This would be 
capable of increasing the risk for different noncommunicable diseases in youngsters and the elderly 
(Furnan et al. 2019). 
 
A growing body of evidence has indicated that mastocytes (MCs) are involved in the pathogenesis of 
inflammation of the brain and neuropsychiatric disorders, and were capable of aggravating 
neuroinflammation. The studies indicated that in addition to ADHD exhibiting a high level of 
comorbidity with allergic and autoimmune diseases, the disorder has also been shown to induce a 
highly inflammatory state. In this review, the association between MCs and ADHD was perceived to 
lack evidence, however, it could provide a new perspective for the treatment of ADHD (Song et al. 
2020). 
 
5. CONCLUSION 
 
The researches indicated strong relations between ADHD and low levels of RS, with increase in 
negative outcomes in adolescence, such as academic failure, lower self-esteem and development of 
anxiety and depression disorders. Whereas it was observed that social support and consolidation of 
measures of sense of self-conception, self-worth and self-confidence, as well as lifestyle were related 
to the occurrence of positive results in this Group, with the perception of competence at school and 
social acceptance. 
 
The family members of individuals with ADHD also had more propensity to developing anxiety and 
depression disorders, which could be explained by the fact they share endophenotypes and by their 
exposure to similar factors that induce resilience, such as family conflicts and adversities. 
 
As non medication intervention, apart from psychotherapy and meditation, changes in lifestyle could 
reduce the chronic systemic inflammation and contribute to the prevention of and improvement in 
ADHD symptoms. 
 
 
 
 
 
 
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COMPETING INTERESTS 
 
Authors have declared that no competing interests exist. 
 
REFERENCES 
 
1. Luo Y, Weibman D, Halperin JM, Li X. A review of heterogeneity in attention deficit/hyperactivity 
disorder (ADHD). Frontiers in Human Neuroscience. 2019;13. 
Available:https://doi.org/10.3389/fnhum.2019.00042 
2. Bora EPC. Meta-analysis of social cognition in attention- deficit/hyperactivity disorder (ADHD): 
comparison with healthy controls and autistic spectrum disorder. Psychological Medicine. 
2016;46(4):699–716. 
Available:https://doi.org/https://doi.org/10.1017/S0033291715002573P 
3. Polanczyk G., de Lima MS, Horta BL, Biederman J, Rohde LA. The worldwide prevalence of 
ADHD: A systematic review and metaregression analysis. The American Journal of Psychiatry. 
2007;164(6):942–948. 
Available:https://doi.org/10.1176/ajp.2007.164.6.942 
4. Simon V, CzoborP, Bálint S, Mészáros Á, Bitter I. Prevalence and correlates of adult attention-
deficit hyperactivity disorder: Meta-analysis. British Journal of Psychiatry. 2009;194(3):204–211. 
Available:https://doi.org/10.1192/bjp.bp.107.048827 
5. Frazier TW, Youngstrom EA, Glutting JJ, Watkins MW. ADHD and Achievement. Journal of 
Learning Disabilities. 2007;40(1):49–65. 
Available:https://doi.org/10.1177/00222194070400010401 
6. Mastoras SM, Saklofske DH, Schwean VL, Climie EA. Social support in children with ADHD: An 
exploration of resilience. Journal of Attention Disorders. 2018;22(8):712–723. 
Available:https://doi.org/10.1177/1087054715611491 
7. McCrimmon AW, Climie EA, Huynh S. The relation between emotional intelligence and 
resilience in at-risk populations. Developmental Neurorehabilitation. 2018;21(5):326–335. 
Available:https://doi.org/10.1080/17518423.2017.1387873 
8. Schei J, Nøvik TS, Thomsen PH, Lydersen S, Indredavik MS, Jozefiak T. What predicts a good 
adolescent to adult transition in ADHD? The role of self-reported resilience. Journal of Attention 
Disorders. 2018;22(6):547–560. 
Available:https://doi.org/10.1177/1087054715604362 
9. Weissenberger S, Ptacek R, Klicperova-Baker M, Erman A, Schonova K, Raboch J, Goetz M. 
ADHD, Lifestyles and comorbidities: A call for an holistic perspective - from medical to societal 
intervening factors. Frontiers in Psychology. 2017;8:454. 
Available:https://doi.org/10.3389/fpsyg.2017.00454 
10. (APA), A. P. A. Diagnostic and Statistical Manual of Mental Disorders (DSM–5) (5a); 2013. 
Available:https://www.psychiatry.org/psychiatrists/practice/dsm 
11. Chang Z, Lichtenstein P, Asherson PJ, Larsson H. Developmental twin study of attention 
problems. JAMA Psychiatry. 2013;70(3):311. 
Available:https://doi.org/10.1001/jamapsychiatry.2013.287 
12. Faraone SV, Perlis RH, Doyle AE, Smoller JW, Goralnick JJ, Holmgren MA, Sklar P. Molecular 
genetics of attention- deficit/hyperactivity disorder. Biological Psychiatry. 2005;57(11):1313–
1323. 
Available:https://doi.org/10.1016/j.biopsych.2004.11.024 
13. Biederman Joseph. Attention-deficit/hyperactivity disorder: A selective overview. Biological 
Psychiatry. 2005;57(11):1215–1220. 
Available:https://doi.org/10.1016/j.biopsych.2004.10.020 
14. McGough J. Adult attention deficit hyperactivity disorder: Moving beyond DSM-IV. American 
Journal of Psychiatry. 2006;163(10):1673. 
Available:https://doi.org/10.1176/appi.ajp.163.10.1673 
15. Purper-Ouakil D, Ramoz N, Lepagnol-Bestel AM, Gorwood P, Simonneau M. Neurobiology of 
attention deficit/hyperactivity disorder. Pediatric Research. 2011;69(5 Part 2):69R-76R. 
Available:https://doi.org/10.1203/PDR.0b013e318212b40f 
 
 
 
Research Trends and Challenges in Medical Science Vol. 9 
Resilience and ADHD: What is New? 
 
 
 
11 
 
16. Ranby KW, Boynton MH, Kollins SH, McClernon FJ, Yang C, Fuemmeler BF. Understanding 
the phenotypic structure of adult retrospective ADHD symptoms during childhood in the United 
States. Journal of Clinical Child & Adolescent Psychology. 2012;41(3):261–274. 
Available:https://doi.org/10.1080/15374416.2012.654465 
17. Biederman J, Spencer T, Lomedico A, Day H, Petty CR, Faraone SV. Deficient emotional self-
regulation and pediatric attention deficit hyperactivity disorder: A family risk analysis. 
Psychological Medicine. 2012;42(3):639–646. 
Available:https://doi.org/10.1017/S0033291711001644 
18. Barkley RA, Cox D. A review of driving risks and impairments associated with attention-
deficit/hyperactivity disorder and the effects of stimulant medication on driving performance. 
Journal of Safety Research. 2007;38(1):113–128. 
Available:https://doi.org/10.1016/j.jsr.2006.09.004 
19. Froehlich TE, Lanphear BP, Epstein JN, Barbaresi WJ, Katusic SK, Kahn RS. Prevalence, 
recognition, and treatment of attention- deficit/hyperactivity disorder in a national sample of US 
Children. Archives of Pediatrics & Adolescent Medicine. 2007;161(9):857. 
Available:https://doi.org/10.1001/archpedi.161.9.857 
20. Rodillo BE. Trastorno por déficit de atención e hiperactividad (TDAH) en adolescentes. Revista 
Médica Clínica Las Condes. 2015;26(1):52–59. 
Available:https://doi.org/10.1016/j.rmclc.2015.02.005 
21. Young S, Hollingdale J, Absoud M, Bolton P, Branney P, Colley W, Woodhouse E. Guidance for 
identification and treatment of individuals with attention deficit/hyperactivity disorder and autism 
spectrum disorder based upon expert consensus. BMC Medicine. 2020;18(1):146. 
Available:https://doi.org/10.1186/s12916-020-01585-y 
22. Young S, Hollingdale J, Absoud M, et al. Guidance for identification and treatment of individuals 
with attention deficit/hyperactivity disorder and autism spectrum disorder based upon expert 
consensus. BMC Med. 2020;18:146(2020). 
Available:https://doi.org/10.1186/s12916-020-01585-y 
23. Mikami AY, Hinshaw SP. Resilient adolescent adjustment among girls: Buffers of childhood 
peer rejection and attention- deficit/hyperactivity disorder. Journal of Abnormal Child 
Psychology. 2006;34(6):823–837. 
Available:https://doi.org/10.1007/s10802-006-9062-7 
24. Publication AP. Diagnostic and statistical manual of mental disorders. DSM-5; 2013. 
Available:https://books.google.com.br/books?hl=pt-BR&lr=&id=- 
JivBAAAQBAJ&oi=fnd&pg=PT18&dq=diagnostic+and+statistical+mental+d 
isorders&ots=ceSN16OHyc&sig=VBVXcQ2KuBON36zYhC84Nflx_- 
o#v=onepage&q=diagnostic and statistical mental disorders&f=false 
25. Regalla MAR, Segenreich D, Guilherme PR, Mattos P. Resilience levels among adolescents 
with ADHD using quantitative measures in a family-design study. Trends in Psychiatry and 
Psychotherapy. 2019;41(3):262–267. 
Available:https://doi.org/10.1590/2237-6089-2018-0068 
26. Koller SH, Lisboa C. Brazilian approaches to understanding and building resilience in at-risk 
populations. Child and Adolescent Psychiatric Clinics of North America. 2007;16(2):341–356. 
Available:https://doi.org/10.1016/j.chc.2006.12.002 
27. Luthar SS, Cicchetti D, Becker B. The construct of resilience: A critical evaluation and 
guidelines for future work. Child Development. 2000;71(3):543–562. 
Available:https://doi.org/10.1111/1467-8624.00164 
28. Rutter Michael. Implications of resilience concepts for scientific understanding. Annals of the 
New York Academy of Sciences. 2006;1094:1–12. 
Available:https://doi.org/10.1196/annals.1376.002 
29. Rutter M. Resilience as a dynamic concept. Dev. Psychopathol. 2012;24(1469-2198 
(Electronic)):335–344. 
30. Rutter Michael. Psychosocial resilience and protective mechanism. Am J Orthopsychiatry. 
1987;57(3):316–331. 
31. Vanderbilt-Adrience Ella, Shaw Daniel S. Protective factors and the development of resilience in 
the context of neighborhood disadvantage. Journal of Abnormal Child Psychology, [S.L.]. 2008; 
36(6):887-901. Springer Science and Business Media LLC. 
Available:http://dx.doi.org/10.1007/s10802-008-9220-1. 
 
 
 
Research Trends and Challenges in Medical Science Vol. 9 
Resilience and ADHD: What is New? 
 
 
 
12 
 
32. Lee SS, Sibley MH, Epstein JN. Attention-deficit/hyperactivity disorder across development: 
Predictors, resilience, and future directions. Journal of Abnormal Psychology. 2016;125(2):151–
153. 
Available:https://doi.org/10.1037/abn0000114 
33. Regalla MA, Guilherme P, Aguilera P, Serra-Pinheiro MA, Mattos P, Regalla MA, Mattos P. 
Attention deficit hyperactivity disorder is an independent risk factor for lower resilience in 
adolescents: a pilot study. Trends in Psychiatry and Psychotherapy. 2015;37(3):157–160. 
Available:https://doi.org/10.1590/2237-6089-2015-0010 
34. Ray AR, Evans SW, Langberg JM. Factors associated with healthy and impaired social 
functioning in young adolescents with ADHD. Journal of Abnormal Child Psychology. 2017; 
45(5):883–897. 
Available:https://doi.org/10.1007/s10802-016-0217-x 
35. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and 
meta-analyses: The PRISMA statement. PLoSMedicine. 2009;6(7):e1000097. 
Available:https://doi.org/10.1371/journal.pmed.1000097 
36. Nigg J, Nikolas M, Friderici K, Park L, Zucker RA. Genotype and neuropsychological response 
inhibition as resilience promoters for attention-deficit/hyperactivity disorder, oppositional defiant 
disorder, and conduct disorder under conditions of psychosocial adversity. Development and 
Psychopathology. 2007;19(3):767–786. 
Available:https://doi.org/10.1017/S0954579407000387 
37. Modesto-Lowe V, Yelunina L, Hanjan K. Attention- deficit/hyperactivity disorder: A shift toward 
resilience? Clinical Pediatrics. 2011;50(6):518–524. 
Available:https://doi.org/10.1177/0009922810394836 
38. Ros R, Graziano PA. Social functioning in children with or at risk for attention 
deficit/hyperactivity disorder: A meta-analytic review. Journal of Clinical Child & Adolescent 
Psychology. 2018;47(2):213–235. 
Available:https://doi.org/10.1080/15374416.2016.1266644 
39. Daley D, van der Oord S, Ferrin M, Danckaerts M, Doepfner M, Cortese S, Sonuga-Barke EJS. 
Behavioral interventions in attention-deficit/hyperactivity disorder: A meta-analysis of 
randomized controlled trials across multiple outcome domains. Journal of the American 
Academy of Child & Adolescent Psychiatry. 2014;53(8):835-847.e5. 
Available:https://doi.org/10.1016/j.jaac.2014.05.013 
40. Smalley SL, Loo SK, Hale TS, Shrestha A, McGough J, Flook L, Reise S. Mindfulness and 
attention deficit hyperactivity disorder. Journal of Clinical Psychology. 2009;65(10):1087–1098. 
Available:https://doi.org/10.1002/jclp.20618 
41. Bögels S, Hoogstad B, van Dun L, de Schutter S, Restifo K. Mindfulness training for 
adolescents with externalizing disorders and their parents. Behavioural and Cognitive 
Psychotherapy. 2008;36(2):193–209. 
Available:https://doi.org/10.1017/S1352465808004190 
42. Pascual CT, VS. Benefits of meditation in adolescents with attention deficit/hyperactivity 
disorder: a narrative review. Rev. Psiquiat.Infanto-Juv. 2013;30(4):19–23. 
Available:https://pesquisa.bvsalud.org/portal/resource/pt/ibc-186125 
43. Evans S, Ling M, Hill B, Rinehart N, Austin D, Sciberras E. Systematic review of meditation-
based interventions for children with ADHD. European Child & Adolescent Psychiatry. 
2018;27(1):9–27. 
Available:https://doi.org/10.1007/s00787-017-1008-9 
 
 
 
 
 
 
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Biography of author(s) 
 
 
 
J. V. C. Freire 
Metropolitan Union for the Development of Education and Culture, UNIME, Brazil. 
 
Academic of the 7th semester of Medicine at the Metropolitan Union of Education and Culture (UNIME). 
Scientific Initiation participant in the last two years, conducting research in the field of Mental Health, as a volunteer and fellow 
(2019-2020) at the National Foundation for the Development of Private Higher Education (FUNADESP). Presented works on 
Mental Health and Integrative and Complementary Practices (PIC) in national congresses. Chapter published: BDNF and 
anxiety disorders in book "Neurological and Mental Disorders - IntechOpen" - DOI: 10.5772 / intechopen.9234. He is President 
of the UNIME Interdisciplinary Academic League of Psychiatry (LAIP). 
 
 
 
R. A. Cerqueira 
Metropolitan Union for the Development of Education and Culture, UNIME, Brazil. 
 
Metropolitan Union for the Development of Education and Culture, UNIME, Brazil. 6th year medical student at the Metropolitan 
Union for the Development of Education and Culture, Brazil - UNIME. It has a chapter published in the book "Child and 
Adolescent Health: Guidance and Monitoring Instruments" - 10.22533 / at.ed.17720110218, in the book "Neurological and 
Mental Disorders - IntechOpen" - DOI: 10.5772 / intechopen.92341 and in the book " PROMEDE - Emergency Medicine Update 
Program: cycle 3 "- ISBN: 978-65-5848-105-8. Former scholarship holder and current volunteer in the Scientific Initiation 
Program - PIC of FUNADESP. Acted as monitor of Medical Skills and metabolism. He was part of the Academic Athletic 
Association of Medicine - UNIME, in the position of Director of Sports, of the Academic League of Nephrology and Urology of 
the Faculty of UNIME (LANURO) and of the Academic Council, in the position of Extension Director, of the Academic League of 
Applied Infectology at Bahia (LAIA) of the Faculty of Medicine and Public Health as Financial Director. Currently a Senior 
Member of the Academic League of Trauma (LBT) of the Faculty of Medicine of UNIME. Awarded work at the XXVIII Brazilian 
Congress of Anatomy, at the VI North-Northeast and Midwest Congress of Anatomy and at the 1st Shock and Trauma 
Workshop. Trainee in Thanatology at the Legal Medical Institute - IMLNR. 
 
 
 
D. F. Sousa 
Metropolitan Union for the Development of Education and Culture, UNIME, Brazil. 
 
Sixth-year student in Medical School, who has been passionate about subjects related to Mental Health even before starting 
college. Took part in a research group that published the chapter: “BDNF Protein and Anxiety Disorders” in a book called 
“Neurological and Mental Disorders”. His goal is to work on as much research as possible, in order to learn about new angles 
and discover new scientific approaches to mental disorders. His thoughts are that scientists have made uncountable efforts and 
 
 
 
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Resilience and ADHD: What is New? 
 
 
 
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research in order to provide the best treatment for mental disorders, but there are still lots of room to discover main factors that 
cause the onset of such diseases, and also efforts that could be done to early identify or even prevent them as well. That’s 
undoubtedly the future direction of research on Mental Health, and he wants to take part in it. 
 
 
 
J. F. A. Novaes 
Metropolitan Union for the Development of Education and Culture, UNIME, Brazil. 
 
Research and Academic Experience: Research in Mental Health and Resilience 
Academic of the 5th semester of Medicine in Metropolitan Union for the Development of Education and Culture Brazil. 
Volunteer in the Scientific Initiation Program—UNIME, in PIC by FUNADESP. Acts as monitor of Anatomy and Histology. 
Member of the Academic Directory of the Medical Faculty in UNIME as research director, the Academic League of Clinical 
Medicine (LACM), as vice president, and of the Interdisciplinary Academic League of Psychiatry (LAIP), as research vice-
director 
 
Research Area: Medicine and Human Health 
 
 
 
T. M. Farias 
UNIME - Metropolitan Union for the Development of Education and Culture, Federal University of Bahia (UFBA), Federal 
Government Economy Ministry, Brazil. 
 
Graduated in Medicine at the Bahiana School of Medicine and Public Health (1998), Specialist in Occupational Medicine 
(Residency in Preventive and Occupational Medicine in 2001), when did an internship at the University of Massachusetts, in 
Lowell (MA), in the Department of Work Environment (2001 ). Master in Medicine and Health from the Federal University of 
Bahia (2004), having participated in the Research Group on Teacher Health, whose master's dissertation had the title of “Voice 
of the Professor: Relationship between Health and Work”. Specialist in Medical Expertise and Legal Medicine (2014) by the 
Brazilian Association of Legal Medicine and Medical Expertise, specializing in Psychiatry at the University Center Philadelphia 
(2018). Professor, for ten years, of undergraduate health courses (teaching Research Methodology and health and safety at 
work), in addition to Postgraduate courses such as: Occupational Medicine and Medical Expertise. Federal Medical Expert of 
the Ministry of Economy, where she was a member of the Medical Ethics Committee and lectured on prevention and health 
promotion by the Quality of Life at Work Service. Professor of the Medicine Graduation at UNIME, in Lauro de Freitas-BA, and 
in the medical skills laboratory, teaching psychiatricsemiology. Professor of the Post-Graduation in Safety and Labor 
Engineering at the Federal University of Bahia. Participated in the elaboration of the self-care project for the UNIME medical 
students. Researcher in Mental Health, financed by FUNADESP, having published the chapter “BDNF Protein and Anxiety 
Disorders” in the book Mental and Neurological Problems. Recently, completed her training in Foundations of Lifestyle Medicine 
Review, and has been dedicated to lifestyles studies, neuroinflammation and mental health. 
 
 
 
 
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S. F. M. Cal 
Metropolitan Union for the Development of Education and Culture, UNIME, Brazil. 
 
Research and Academic Experience: Researcher and professor at the Professor of the Medical School and Postgraduate 
Course. Scientific journal reviewer, editorial board member. Clinical psychologist, Doctor and Master in Medicine and Health by 
the Bahiana School of Medicine and Public Health. Acts as a psychotherapist with training in Analytical Psychology and 
Humanistic Psychology. She has the title of specialist in Clinical Psychology by the Regional Council of Psychology, with 
experience in depression and psychosomatics. Professor of the Medical Course at UNIME. Invited professor of the Analytical 
Psychology Course at the Federal University of Bahia. Reviewer of scientific journals such as British Journal of Medicine and 
Medical Research, Cogent Psychology and Psychology Health and Medicine. Ad hoc consultant for the newspaper “Texto e 
Contexto”. Member of the editorial board of the Journal of Arthritis and Rheumatism and Psychology & Psychological Research 
International Journal. Among the published articles, the one that had the greatest impact was Resilience and chronic Disease: 
the systematic review. Chaper published: BDNF and anxiety disorders book "Neurological and Mental Disorders - IntechOpen" 
- DOI: 10.5772 / intechopen.9234 Psychological Resilience and Immunity- In book: Innovative Immunology. Publisher: Austin 
Publishing Group. 
 
Research Area: Health, Psychology, Medicine 
 
Number of Published papers: 12 papers, 2 books, 2 book chapters 
 
Any other remarkable point(s): Doctor and Master’s in Medicine and Human Health. 
_________________________________________________________________________________ 
© Copyright (2021): Author(s). The licensee is the publisher (Book Publisher International).