A Preliminary Investigation of ADHD Symptoms in Persons With Celiac Disease

Abstract

Several studies report a possible association of celiac disease (CD) with psychiatric and psychological disturbances, such as ADHD.
The authors assess 132 participants from 3 to 57 years of age (M = 19.3 years) affected by CD for the possibility of an associated ADHD-like symptomatology, using the Conner Scale Hypescheme, a behavioral scale similar to the Conners Rating Scales, before their gluten-free diet was started and 6 months later.
The overall score improves significantly as well as most of the ADHD-like symptomatology specific features (Bonferroni-corrected, paired-sample t tests).
The data indicate that ADHD-like symptomatology is markedly overrepresented among untreated CD patients and that a gluten-free diet may improve symptoms significantly within a short period of time. The results of this study also suggest that CD should be included in the list of diseases associated with ADHD-like symptomatology.

Full text

A
Pretiminary
Investigation
of
ADHI)
Symptoms
in
Persons
With
Celiac
f)isease
Helnut
Niederhofer
Klaus
Pittschieler'
Reg,ional
Hospital
of
Bolzano,
Ital¡'
Objective:
Several
stuclies
report a
possible
association
ofceliac
disease
(CD)
with
psychiatúc and
psychological
distulbances.
,u.h
o.
ADHD.
Method:
The
authors
assess
132
participants
fronl 3
to
-57
years of
age
(M
=
19.3
years) affected
by CD
for
the
possibility
of an
associated
ADHD-like
symptolnatology.
using
the Conner
Scale
Hypeschetne,
a behavio¡al
scale
similar'
to
the Conuer.s
Rating
Scales,
before
their
gluten-fi'ee diet
was
started
ancl
6 months
later.
Results:
The
ovel'all
score
irnpt'oves
signifìcantly
as
well
as most
of the
ADHDIike
syrnptontatology
specific
featrrres
(Bonferroni-conected,
paired-sanrple
t tests)'
Cónclusion:
The tlata
indicate
that ADHD-like
symptomatology
is
nrarte<Jly
ovenepreseutecl
arnong
untreated
cD
patients
ancl
th¿rt
a
gl.ten-tì-ee <Jiet
nray
inrprove
sylnptoms
significantly
rvithin
a short
peliod of
time.
The
results
of this
study also
suggesr
ttroi
CO
shoulcl he
inclucled
in the
list of
diseases
associated
with
ADHD-like
symptornatologv.
Keyv,ords:
AHDH;
celictc
disease
rlelïacdisease
(CD)
is
a destructive
inflammatory
dis-
\-,.0r"
of the
mucosa
of
the upper
small
intestine
lesulting
from
gluten ingestion
in
genetically
susceptible
inclividuals.
The diagnosis
is based
on
demonstration
of
a rnore
or
less
pronounced
villus
atrophy
in
a
jejunal
biopsy
(Feigbery,
1999;
Maki
& CoHin,
1997)'
The ther-
apy
consists
of
excluding
gluten
pernlarrently
from the
diet
ancl
allows
a total
healing
of
the
tnucosal
lesion.
Since
the
early
1980s,
it
has
become
evident
that
CD
is
underdiagnosed
(Catassi
et al.,
1996:
Feigbery.
1999;
Kolho,
Farkkila,
& Savilahti,
1998;
Maki
& CoHin.
1997;
Rolmes,
1996).
In
young Italians
ages 6
to
l5' the
overall
prevalence
of CD
was I
in I 84.
screened
by com-
binecl
cletermination
of
serttm
immunoglobulin
G
(IgG)
ancl
IgA
antigliadin
antibodv
test
(Catassi
et al.,
1996)'
Anrong
healthy
Finnish
adults'
the
prevalence
was as
high
as
I in
130
using
IgA
antiendomysium
antibody
cletermination
(Kolho
et al.,
1998).
Presentation
with
minor
sytnptoms,
such
as in'itable
bowel
syndrome,
ane-
rnia, slight
weight
loss,
and
fatigue,
has
become
increas-
ingly
comrnon,
and
in
many
cases,
the
disease
may
be
clinicarlly
silent,
despite
manifesting
small-bowel
mucosal
lesions.
If undetected
or
neglected,
CD
may
calìse
colì-
siderable
late
conlplications
fi'oln
malabsorption
or sec-
ondaly
autoimmune
diseases
(Feigbery,
1999;
Maki
&
CoHin.
1997;
Rolmes,
1996)
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of
Attcnl¡on Disordcrs
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sâg('lub coilì
Neurological
dysfunction
(Hadjivassilou et al.,
1996;
Hadjivassilou
et al.,
l998lRolnres,
1996)
and
psychiatric
symptoms
ale
corlmon
in CD
(Ciacci,
Lavarone,
Mazzacca,
&
De
Rosa,
1998;
Hallert
&
Astrom'
1982;
Hallert
&
Derefeldt,
1982;
Rolmes,
1996).
Depressive
symptoms
often
f-eature
in CD
of
adults,
regaldless
of treat-
ment
ancl
age at
diagnosis
(Ciacci
et
al.,
1998).
Irt sotlle
cases,
depressive
syt.t.tptotns
have
reportedly
imploved
soon
after
starting
a
gluten-free
diet
(Corvaglia,
Catanlo,
Pepe,Lazz'ani,
& Corvaglia.
1999).
The
prevalence of
severe
nlental
and behavioral
disordet's
in
untreated
CD
is unknown,
but
a
history
of
psychiatlic
tt'eatnrent
before
the
cliagnosis
of
CD
has been
reported
in 2lolo
(9
out of
42) of
acluìt
CI)
patients
conpared
with
-57c
(2
out of
42)
of a
meclical
contlol
gloup
(Hallert
&
Astrom,
1982;
Hallert
&
Derefeldt,
1982).
We observed
that
many
patients afTected
by
a
rnore
ol'
less
overt
CD
showed
Authors'Note:
Acldress
corespondence
to
Susan
G. Crawford,
Behavioural
Research
Unit,
Alberta
Children's
Hospial,
2888
Shaganappi
Tlail
NW,
Calgary,
Alberta,
Canada
T3B 648;
phone:
(403)
943-7365;
e-mail:
susan.crawford@calgary-
healthregion.ca.
The authors
thank
Alberta
Mental
Health
Resealch
Fund
and
the Albelra
Children's
Hospital
Fotlndation
for
financial
support
ancl Br'enda
Wilson,
M'S.,
O1"(C)'
for
helping
organiz.e
atrcl
collcluct
the
lnotor
skills
assesslnents'

2 Journal
of Attention
Disorders
signs
of
ADHD-like
symptomatology
before
initiating
a
dìetetic
treatment,
and
therefore.
we
were
interested
in
observing
whether
a
gluten-free
diet
could
alleviate
those
behavioral
sYurPtous.
designed
to
replace
cuffellt
assessllent
protocols
but
to
be
a
final
colnmon
checklist
that
can
be
completed
by
experiencecl
researchers
using
all
available
data
(Curran'
Newman,
Taylor,
&
Asherson,
2000).
This
tnethod
uses
a
coding
fot'm
to
summarize
sarnple
characteristics,
aspects
of
the
ADHD-like
symptomatology
phenotype'
anà
other
key
data.
The
Hypescheme
does
not
require
investigators
to
collect
data'
Instead,
it sp
information
to
be
collected
,
a common
for-
nat.
It includes
the
following
areas:
demographic
data,
symptoms
of
DSM-IV
ADHD
and
ICD-10
hyperkinesis
(át
trome
and
school),
symptoms
of
oppositional
and
conduct
disorders,
sumlxary
symptoms
of
specihc
anxi-
ety
disorders,
sumlnary
symptoms
of
other
psychiatric
disorders,
summary
symptoms
of
developmental
(lan-
guage
a
learning)
disorders,
IQ
(verbal, performance,
ãnd-full
scale),
associated
neurological
conditions'
and
questions
regarding
medication
use
and
efficacy'
Only
in
absence
of
cornorbidities,
ADHD
can
be
diagnosed'
Each
site
can
transfer
data
into
the
Hypescheme
fbrmat
flom
whatever
inst.rutneuts
wel'e
currelltly
used
for
data
collection.
This
allows
the
creation
of
a
courmou
data
set
clirected
Conner
Scale.
This
facilitates
subtyping
across
sites
at
the
symptom
level'
Using
the
Hypescheme
does
not
require
a signihcant
amount
of
extra
work'
Rather'
it
provides
a
set
of
organizing
principles
and
common
data
itructure
for
clata
that
have
ah'eady
been
collected
by
most
sites.
tonrs
hefot'e
and
6
months
after
the
diagnosis
and
dietetic
treatment
of
CD.
Method
One
hundred
ancl
thirty-two
participants
ranging
tn
age
from
3
ro 51
(M
=
d
diagnosed
according
to
a'
weã
asked
to
particiPa
d
ium
antibodies
demon-
g
the
human
umbilical
atients
carried
elevated
tissue
transglutaminase
antibodies
using
the
human
recombinant
antigen
as
substrate
(Pharmacia)'
The histo-
logical
examination
of
jejunal
or
duodenal
mucosa
sllowe,l
in
all
patients
a total
a
partial
villous
atrophy
and
for
the
CD
specihc
inflamtnatory
features'
Fifty-four
Patients
were
not
Thirty-six
of
the
remaining
78
females.
No
significant
differe
and
nonparticipants
were
found
in
gastro-intestinal
or
nralabso
ption symptoÍlls
and
nlelltal
disorders'
Severe
mental
disordels,
such
as
psychosis,
major
depression'
ancl
drug
dependency,
wet'e
exclusion
cornitant
diagnosis
of
autoimmune
di
rvith CD,
such
as
diabetes
mellitus
and
Redlich.
1958).
All
adult
patients
and
parents
of inclucled
ADHD-like
,:ili;J.ii;
disorder,
ancl
conduct
disorder
and
is
proposed
as
a
min-
imuur
data
set
for
those
engagecl
in
molecular
genetic
studies
of
ADHD.
Hypescheme
consists
of
a computer-
ized
data
checklist
system
that
includes
all
the
opera-
tionalcriteriarequiredforbothDiagnosticarrdStatistìcal
Manual
of
Mental
Disorders
(4th
ed';
DSM-lV;Arnerican
Psychiatric
Association,
1994)
and
International
Classifi-
caiion
of
Diseases-Version
l0
(ICD-10)
diagnostic
crite-
diagnostics
under
both
these
systems'
Hypescheme
is
not