Tzang RF, Lin YW, Kao KL, Chang YC, Huang HC, Wu SY, Wu SI, Stewart R. Subsequent psychiatric disorders in attention deficit and hyperactivity children receiving speech therapy. World J Psychiatry 2025; 15(5): 100731 [DOI: 10.5498/wjp.v15.i5.100731]
Corresponding Author of This Article
Shu-I Wu, MD, PhD, Professor, Department of Medicine, Mackay Medical College, No. 92, Section 2, Zhongshan Road, Taipei 252, Taiwan. t140@mmc.edu.tw
Research Domain of This Article
Pediatrics
Article-Type of This Article
Observational Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Author contributions: Tzang RF, Chang YC, Kao KL, Lin YW, and Wu SI designed the study and wrote the protocol; Lin YW and Wu SI undertook the statistical analysis; Tzang RF wrote the first draft of the manuscript; Wu SY is the primary SLP advisor for this study; Tzang RF, Lin YW, Kao KL, Chang YC, Huang HC, Wu SY, Wu SI, and Stewart R contributed to this manuscript and have approved the final manuscript.
Institutional review board statement: The present study was approved by the Research Ethics Committee of China Medical University and Hospital, Taichung, Taiwan, No. CMUH104-REC2-115(CR-3).
Informed consent statement: Our study subjects were identified from the Taiwan National Health Insurance Research Database. Due to the anonymization and encryption of all information from the National Health Insurance Research Database, patient personal identities were not revealed.
Conflict-of-interest statement: The authors declare that they have no conflict of interest to disclose.
STROBE statement: The authors have read the STROBE Statement—a checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-a checklist of items.
Data sharing statement: Since very simple statistics were used in this study, it did not require a review by a statistician.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Shu-I Wu, MD, PhD, Professor, Department of Medicine, Mackay Medical College, No. 92, Section 2, Zhongshan Road, Taipei 252, Taiwan. t140@mmc.edu.tw
Received: August 29, 2024 Revised: December 16, 2024 Accepted: March 7, 2025 Published online: May 19, 2025 Processing time: 244 Days and 8 Hours
Abstract
BACKGROUND
Speech and language therapy (ST) might moderate the prognosis in children with attention deficit and hyperactivity disorder (ADHD) comorbid with speech delay. This study investigated whether ST in children with ADHD is associated with a decreased risk of subsequent psychiatric disorders.
AIM
To investigate whether ST in children with ADHD is associated with a decreased risk of subsequent psychiatric disorders.
METHODS
The population-based National Health Insurance Research Database in Taiwan was used. Hazards of subsequent psychiatric disorders were compared between those who received ST and a propensity-score matched comparison group by Cox regression analyses.
RESULTS
Of 11987 children with ADHD identified from the dataset, 2911 (24%) had received ST. The adjusted hazard ratio for any subsequent recorded psychiatric disorder was 0.72 (95% confidence interval: 0.63-0.82) in children who received ST compared to the matched counterparts. This protective association was only statistically significant in the subgroup that received both medication and behavioral interventions.
CONCLUSION
ST can moderate the effects of integrated early interventions in ADHD children with speech delay.
Core Tip: Speech therapy can moderate the treatment effect for attention deficit and hyperactivity disorder (ADHD) children with speech delay problem. Speech therapy in children with ADHD is associated with a decreased risk of subsequent psychiatric disorders. Multi-modal managements including medication and behavioral intervention may help strengthen the protective effect in addition to getting speech therapy.
Citation: Tzang RF, Lin YW, Kao KL, Chang YC, Huang HC, Wu SY, Wu SI, Stewart R. Subsequent psychiatric disorders in attention deficit and hyperactivity children receiving speech therapy. World J Psychiatry 2025; 15(5): 100731
Attention deficit and hyperactivity disorder (ADHD) is a common neurodevelopmental disorder[1] that has heterogeneous symptom expressions[2]. In preschool children, some symptoms of ADHD, such as excessive talking, intruding on others’ conversations, and shouting out answers before questions have finished, are believed to involve co-occurring pragmatic speech difficulty or language dysfunctions[3]. Thus, children with ADHD had a higher risk of developing speech or language difficulties; the prevalence was 26%-66%[4-6]. Generally, children with ADHD have been found to have a 2.8 times higher risk of language problems than those without[7]. In a large population-based study in kindergarten children aged 5-6 years, the prevalence of ADHD comorbid with language impairments was 3%-5%[3].
Language is crucial for the normal development of multiple cognitive and socioemotional abilities in children[8]. Notably, impairments in language development during childhood are highly associated with maladjustments and behavioral problems. Previous studies demonstrated that children with a history of language delay and persistent language difficulties had higher incidences of subsequent psychiatric morbidities or problem behaviors than those whose language problems were treated earlier[9,10]. These problem behaviors associated with speech delay may include internalizing behaviors, such as anxiety, depression, and social isolation, and externalizing behaviors, including aggressiveness, convictions, and arrests[11,12]. Higher risk of social and attention difficulties was found in children with ADHD and language problems than in those with ADHD without language problems[9,10]. Approximately 30% of children with ADHD show reading and writing delays[10]. Children with ADHD struggle with language, particularly in structural language[13]. Behavioral issues in children with ADHD were negatively correlated with pragmatic language and the use of structural language in communication[14]. Furthermore, language delay has been found to predict risks of developing emotional liability and externalizing problem behaviors in children with ADHD[15-19]. Therefore, early interventions targeted on improving language ability may be beneficial in preventing subsequent internalizing or externalizing behavior problems[18,20,21].
However, speech or language delays in children with ADHD are often unrecognized and untreated in child mental health and community settings[7,10]. In Taiwan, many parents who have children with ADHD and speech problems, even if identified, may only seek speech therapy. Speech and language therapy (ST) corrects vocabulary, grammar, sound, and syllable issues and uses repetitive language exercises to develop language skills and facial exercises to strengthen mouth muscles in a treatment period of 6 months among children that have articulation, fluency, or voice problems; however, it was not established for improving communications or interpersonal skills. Nonetheless, a 2022 systematic review on pragmatic language impairments in children with ADHD revealed that these children exhibit significant challenges in social communication, which may not be adequately addressed by traditional speech therapy alone[22]. This underscores the significance of pharmacotherapy combined with behavior therapy. According to the Multimodal Treatment Study of Children with ADHD, the best treatment for children with ADHD is pharmacotherapy combined with behavior therapy to prevent co-occurring subsequent psychiatric disorders[23] instead of only administering ST for ADHD co-occurring with speech delay. Whether ST in children with ADHD and language problems reduces the risk of subsequent psychiatric disorders remains unclear.
Considering that ST induces more effects than medication or behavioral interventions in this group, the present study analyzed the hazard ratios of developing subsequent psychiatric disorders by further stratifying data based on the types and combinations of other interventions. Such a study may elucidate whether ST can decrease the effect of ADHD on speech delay problems or whether multiple and integrated early interventions including pharmacotherapy, behavior therapy, and ST are more crucial interventions for children with ADHD comorbid with speech delay.
MATERIALS AND METHODS
Data sources
The study participants were identified from the Taiwan National Health Insurance Research Database (NHIRD). Taiwan established the single-payer National Health Insurance (NHI) system, which provides near-universal healthcare for > 99% of its 23 million resident[24]. NHIRD contains all medical claims data from the NHI system, and the present study used data from the Longitudinal Health Insurance Database (LHID), an NHIRD subset that randomly chose 3 million NHI enrollees from all Taiwan residents; at that time, the age and sex distributions of the LHID were not significantly different from those of the general population in Taiwan[25]. LHID includes records of general baseline demographic information such as age, sex, and residential area and all healthcare utilizations from 1996 to 2013, such as outpatient visits, hospitalizations, emergency visits, drug prescriptions, and interventions administered. All diagnoses and interventions were coded using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), and LHID data were only released to researchers for research purposes, with information anonymized and encrypted to protect privacy. The present study was approved by the Research Ethics Committee of China Medical University and Hospital, Taichung, Taiwan, No. CMUH104-REC2-115(CR-3).
Study population
The study included children below 8 years old who were diagnosed with ADHD [ICD-9-CM code: 314, excluding hyperkinesis with development delay (314.1) and hyperkinetic conduct disorder (314.2)] between 1997 and 2008. The participants were divided into two groups based on age, according to suggestions from clinical studies and treatment guidelines that used 4 years as a key dividing point because diagnostic and treatment strategies may differ: Children aged < 4 years and those aged > 4 years[26] (Table 1). Children with ADHD who had medical claims of ST in 1997-2013 with or without the diagnoses of autism, developmental delays, speech or reading delays, mental retardation, cerebral palsy, or hearing loss (ICD-9-CM codes: 299, 314.1, 315, 317-319, 343, 344, and 388) were classified as the intervention group (ST cohort), and those who did not receive ST at any time during that period formed the base population for drawing the comparison group (non-ST cohort). The date of the first claim for ST was set as the index date, and the non-ST cohort was selected from those who had medical visits in the same index year as the study participants. Owing to significant differences in demographic characteristics and comorbidities between the intervention and comparison groups, multivariate logistic regression was performed to calculate the propensity score for each participant in both groups using the following covariates in addition to demographic variables: Sex, age (per 2 years old), urbanization levels, ADHD medications, psychosocial interventions, index year, year of ADHD diagnosis, and comorbidities of autism, developmental delay, speech or reading delay, mental retardation, cerebral palsy, and hearing loss. Participants with similar propensity scores in the non-ST cohort were selected to match with the participants in the ST cohort. Those with non-overlapping outliers in their propensity scores were excluded from the analyses.
Table 1 Comparisons of demographic characteristics in attention deficit and hyperactivity disorder children with or without speech and language therapy before propensity matching, n (%).
Incidence of any subsequent diagnosis of a psychiatric disorder was the main outcome; this was measured from the index date until the end of 2013 and included the following disorders: Schizophrenia, affective disorders, psychosis, emotional disturbances, anxiety, adjustment disorders, impulsive disorders, conduct or oppositional defiant disorders, and personality disorders (ICD-9-CM codes: 295, 296, 298.8, 298.9, 300, 301, 309, 312, and 313). Children from both cohorts who had any of the above psychiatric diagnoses at baseline and those with missing baseline demographic data were excluded. Comorbidities of autistic spectrum disorders, development delay, speech or reading delay, mental retardation, cerebral palsy, and hearing loss (ICD-9-CM codes: 299, 314.1, 315, 317–319, 343, 344, and 388) were identified as covariates, because these comorbidities have therapeutic indications for ST and they may be proxies for severity of mental and/or physical health conditions potentially having independent effects on the outcome. This is critical as these comorbidities could independently influence the study’s outcomes. Urbanization was classified as levels 1 to 5, with level 1 being the most urbanized and level 5 as the least urbanized according to population density, population ratios of people with college or above education levels, people aged > 65 years, agriculture workers, and the number of physicians per 100000 people[27].
Statistical analysis
Differences in categorical variables between the ST and non-ST cohorts were examined using the χ2 test and differences in continuous variables using the Student’s t test. After selecting participants with similar propensity scores, the standardized differences for each covariate in the new propensity score-matched ST and non-ST cohorts were < 0.1, indicating that patients’ characteristics in the ST and non-ST cohorts within each propensity stratum were similar. Incidences of individual and total psychiatric disorders were compared between the two cohorts after propensity matching and stratified by sex, age groups (ADHD diagnosis age under 4 years old or not), and comorbidities. The endpoints of follow-up for the two cohorts were the occurrence of a psychiatric disorder, loss to follow-up (e.g., death or emigration), or the end of December 2013. Multivariate Cox proportional hazards models were used to compare adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) for outcomes between the ST and non-ST cohorts. The hazard ratios of the two groups were stratified as follows: No medication or behavioral intervention, only ADHD medication treatment, only behavioral intervention, and both medication and behavioral interventions. Two-tailed statistical significance was set at P < 0.05. Data were analyzed using the SAS 9.4 statistical package (SAS Institute Inc., Cary, NC, United States).
RESULTS
Before propensity matching, the search from the LHID with 3 million enrollees yielded a sample of 11987 children with a recorded ADHD diagnosis, of which 2911 (24%) had received ST, whereas 9076 (76%) had not (Table 1). Demographic characteristics and comorbidities between children with ADHD in the ST and non-ST cohorts were significantly different (all P values were < 0.01) before propensity score matching. The ST cohort included more boys than girls compared to the non-ST cohort (78.6% vs 77.6%), and mean ± SD ages at study entry (date of ADHD diagnosis) were 4.92 (1.54) and 5.99 (1.47) years, respectively. Moreover, the ST cohort was more prone to comorbidities, such as cerebral palsy, autism, hearing loss, delay development, and mental retardation than the non-ST cohort. Percentages of behavioral intervention were significantly higher in the ST cohort than in the non-ST cohort; however, the percentages of ADHD medication use were significantly less in the ST cohort than in the non-ST cohort. More children lived in areas with higher levels of urbanization in the ST cohort than in the non-ST cohort. After propensity score matching, the distributions of demographic characteristics, comorbidities, and interventions for ADHD were similar in the two cohorts (all standardized differences were < 0.1; P values from χ2 test or analysis of variance were > 0.05; Table 2).
Table 2 Comparisons of demographics and comorbidities between attention deficit and hyperactivity disorder patients that received speech and language therapy (speech and language therapy cohort) and propensity score matched attention deficit and hyperactivity disorder patients without speech therapy (non-speech and language therapy cohort), n (%).
Table 3 summarizes incidences of each psychiatric disorder and the aHRs stratified by age, sex, and comorbidities after propensity matching. A significantly elevated risk of subsequent any psychiatric disorder was noted (aHR = 0.72; 95%CI: 0.63-0.82) in ADHD children without ST. The risk of psychiatric disorder in the ST cohort was 28% lower than that in the non-ST cohort, and hazard ratios were significant only for emotional disturbance, anxiety disorder, and adjustment disorder as individual outcomes. The hazard for any psychiatric disorder remained significantly lower in the ST group than in the non-ST group following stratification for sex and comorbidity and was not significant for the age group of < 4 years.
Table 3 Incidences and hazard ratios of subsequent psychiatric disorders between attention deficit and hyperactivity disorder patients who received speech and language therapy (speech and language therapy cohort) and propensity matched comparison subjects who did not receive speech therapy (non-speech and language therapy cohort as reference group); also stratified by sex, age, and comorbidity.
Table 4 presents the stratification of the primary association by other recorded interventions. In summary, although most remained negative, apart from that in the group receiving behavioral intervention alone, the hazard ratio of interest was significantly decreased only in the subgroup that received both ADHD medication and behavioral intervention (aHR = 0.60; 95%CI: 0.45-0.79).
Table 4 Incidence and adjusted hazard ratios of overall subsequent psychiatric disorders in attention deficit and hyperactivity disorder children with speech and language therapy (speech and language therapy cohort) and propensity matched attention deficit and hyperactivity disorder children without speech therapy (non-speech and language therapy cohort as reference group) upon receiving different interventions for attention deficit and hyperactivity disorder.
To the best of our knowledge, this is the first study to investigate the potential impact of ST on the risk of developing subsequent psychiatric disorders in children with ADHD using population-based, propensity-matched samples. Study findings indicate that ST combined with behavioral and pharmacological treatments reduces the long-term psychiatric consequences of ADHD.
Our finding that risks of overall psychiatric disorders, emotional disturbances, anxiety disorders, and adjustment disorders were significantly lower in the ST cohort than in the non-ST cohort is consistent with that of a previous research describing lower incidences of psychiatric disorders in children whose language delay resolved within 5 years than in those whose delay did not resolve[9]. The correlation between ADHD and spoken language disorders may be elucidated by the fact that language ability is associated with inattentive, hyperactivity, and external behavior problems[18] via poor self-regulatory skills[28]; thus, appropriate ST intervention may be beneficial in reducing the risk of emotional liability and decreasing the occurrence of subsequent violent behaviors or negative mood[3].
Furthermore, ADHD is linked to spoken language disorders because of underlying anatomical and physiological mechanisms. ADHD is associated with dysfunctions or reductions in total brain size in regions such as the prefrontal cortex, basal ganglia, and cerebellum, which are crucial for attention, executive function, and motor control[29]. Additionally, these regions interact with critical language processing areas, including the Broca’s and Wernicke’s areas. Dysfunctions in these areas may cause expressive and receptive language difficulties[30]. Previous research showed that although children with ADHD performed better regarding structural language than those with language development disorders, they were found to be significantly worse than their typically developing peers. Moreover, they performed numerically worse in pragmatics than any other group; however, the differences were not significant[20]. Additionally, ADHD is associated with dysregulation in the dopamine and norepinephrine systems. Neurotransmitter imbalances, particularly those involving dopamine and norepinephrine, may be critical in the regulation of attention, behaviors, language processing, and communications in ADHD[31] and language disorders. In children with ADHD, disruptions in white matter pathways, such as the arcuate fasciculus that connects the Broca’s and Wernicke’s areas, may affect communications between different brain regions involved in language processing and cause language disorders[32]. ST can be beneficial in improving communication more effectively in individuals with ADHD and spoken language disorders by enhancing their expressive and receptive language skills and helping them organize their thoughts and stay on the topic. Further, these may be helpful in enhancing their academic performances and social interactions. The third possible explanation of the association between ADHD and spoken language disorders is the bidirectional relationship between speech and language impairment and ADHD symptoms[5,18]. Disruptions in language learning may lead to poor comprehension, which may aggravate hyperactivity and attention problems[3]. Good attention is critical for developing pragmatic and grammatical skills in language on social routines[3]. Children with impaired language learning may have poor comprehension to express their negative mood, which may aggravate violent behavior later on[3]. That is, ADHD symptoms during childhood may be closely related to poor self-regulatory skills, poor social routine, and difficulty to comprehend children’s negative affect. Hence, effective ST may help reduce the possible negative impacts of attention deficits and language delays that may lead to subsequent violent behaviors or have heightened risk for later mental health problems.
In the present study, the possible protective effect of ST for the decreased risk of later psychiatric disorders was significant only in the subgroup that received both medication and behavioral interventions (Table 4). That is, ST alone may be insufficient and thus should be combined with other treatments to effectively lower the risk. Combined treatment modalities are crucial for preventing or decreasing the severity of comorbid conditions. Parents typically prefer other managements as to medications possibly because of the fear of side effects[33,34]. Additionally, children with ADHD and their families may lack access to guideline-indicated treatment modalities. The results of the present study show that ST provides additional benefits when combined with supplementary behavioral and pharmacological treatments. Thus, early interventions and multimodal treatment may be recommended in addition to pragmatic language skills training for children with ADHD with possible comorbidity of language difficulties, which are best individualized according to personal needs[34,35].
Moreover, the study results (Table 1) outlined the current condition of early intervention treatments in Taiwan. The results indicate that ST may be more available in areas with higher urbanization levels, consistent with previous research describing that children with ADHD living in more urbanized areas had access to more services at an earlier stage[36]. In contrast, < 50% of all the children with ADHD in intervention groups received medication treatment, indicating that inequalities in access remain possible in this near-universal healthcare system. Therefore, more attention should be paid to the under-detection of relevant symptoms of ADHD and/or language difficulties, particularly if early ST is effective in decreasing the risk of poor comprehension[37].
The strengths of this study include the statistical power sufficient to detect associations of interest from a large sample of children with clinically diagnosed ADHD. Additionally, information on ST was obtained from a healthcare system with unrestricted and near-universal coverage. Owing to the random population sample present in the source database, the findings are therefore nationally generalizable. Finally, the effects of the between-group confounding factors measured by applying propensity score-matched comparisons were minimized.
This study has the following limitations. First, there may be selection bias because the diagnoses were drawn from a database established for insurance claims and may not generalize well enough to the ADHD diagnostic criteria applied for research purposes. Underreporting of true ADHD cases or psychiatric disorder outcomes is common in Taiwan. If ADHD cases are underreported, the prevalence rates observed in the present study may be lower than the actual rates in the broader population. The cases that are reported and included in this study may be more severe or have higher rates of comorbid conditions, leading to a sample that does not accurately represent the full spectrum of ADHD severity or an overestimation of the severity and associated impairments of ADHD in the general population. Furthermore, these included cases may have families that have higher awareness of ADHD symptoms and are more likely to seek diagnosis and treatment. This can skew the sample toward families with better access to healthcare, potentially overlooking those from less advantaged backgrounds who may have undiagnosed ADHD. A more thorough investigation of these limitations provides a balanced view of the study’s implications and highlights areas for future research to address these gaps. Second, the generalizability of this study is limited to children with ADHD receiving medical services, and those who did not attend clinically may have been missed. Third, although listed covariates in the matched design, such as demographic characteristics, comorbidities, and intervention receipts, were adjusted, there is possibly other information (e.g., the frequency and sessions of ST; children’s receptive or expressive language ages; their syntax, semantics, or pragmatics; and their screen time exposures or peer socializations) or confounding factors relevant to the risk of developing mental illnesses (e.g., stressful life events or parenting styles) that were not available in this routine administrative data resource, and the actual treatment effect of ST can only be estimated in a randomized controlled clinical trial. In addition, the age groups of above and below 4 years were chosen based on developmental differences and clinical practice considerations[26]. Although such groupings may reflect the differences in language and behavioral development, it may overlook some finer age differences. However, with finer age groupings, there may not be a sufficient sample size for each age group and may not be practical for clinical application and broader generalizations. Future studies employing more comprehensive or granular data collection methods are warranted to provide insights into these aspects and explore how ST reduces the risk of psychiatric disorders, such as the associations of improving communication skills and executive functioning or overall behavioral outcomes, as well as to examine the efficacy of combining ST with pharmacotherapy and behavior therapy at different ages. Fourth, whether it is necessary for all children with ADHD to receive ST is unclear. It should be considered that children undergoing ST may have other severe behavioral disruptions or deficits. This study was based on insurance claims data. Hence, further research is required to determine which specific therapies could reduce the risk of subsequent psychiatric disorders.
Therefore, our findings demonstrate that the risk of subsequent mental illnesses is lower in children with ADHD who had ST than in those who did not. Multimodal management, including medication and behavioral intervention, may strengthen the protective effect in addition to receiving ST. Earlier language assessment in children with ADHD, or early attention assessments in children with language difficulties, and building strong collaborations among children with ADHD, their families, and the multidisciplinary team, including speech therapists and child-adolescent psychiatrists, may help improve the quality of care in children with ADHD. Furthermore, clinical teams should conduct community outreach activities, such as routine early screening for speech and language delays, to enhance parents’ awareness, educate and involve parents in supporting language development at home, and recommend relevant public health plans to fund and make ST services accessible, especially in underserved areas, so that these children can receive appropriate care. Furthermore, good government policies to encourage early, timely, and effective multimodal interventions for ST, medication, and behavioral or psychosocial integration for the holistic treatment of ADHD should be established.
CONCLUSION
To conclude, our findings suggest that the risk of subsequent mental illnesses is lower in ADHD children that had ST than those who did not. Multimodal managements including medication and behavioral intervention may help strengthen the protective effect in addition to getting ST. Earlier language assessment in children with ADHD, or early attention assessments in children with language difficulties, building strong collaborations among ADHD children, their families, and the multidisciplinary team including speech therapists and child-adolescent psychiatrists may help improve the quality of care in children with ADHD. Clinical teams should also make efforts to carry out community outreach activities, such as routine early screening for speech and language delays, to enhance parents’ awareness, to educate and involve parents in supporting language development at home, and to suggest relevant public health plans to fund and make ST services accessible, especially in underserved areas, so that these children can receive appropriate care. Furthermore, good government policies to encourage early, timely, and effective multimodal interventions for ST, medication, and behavioral or psychosocial integration still need to be emphasized for holistic treatment of ADHD.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Psychiatry
Country of origin: Taiwan
Peer-review report’s classification
Scientific Quality: Grade B, Grade B, Grade C
Novelty: Grade A, Grade B, Grade C
Creativity or Innovation: Grade A, Grade B, Grade C
Scientific Significance: Grade B, Grade B, Grade C
P-Reviewer: Koyel D; Zhang JW S-Editor: Fan M L-Editor: Wang TQ P-Editor: Zhang XD
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