Association of ADHD and Celiac Disease: What Is the Evidence? A Systematic Review of the Literature.

Objective: This article tries to answer the question whether or not there is evidence for a relationship between celiac disease (CD) and ADHD. A review of the current literature on this topic is provided. Method: PUBMED/MEDLINE, Web of Science, and Google scholar were searched to include all published trials on ADHD and CD (no date limitation, both noncontrolled and controlled trials). In addition, the reference list of included studies was screened to find other relevant articles. Results: Eight studies report a possible association between CD and ADHD; however, the results are inconsistent. Only three out of eight studies report a positive correlation between ADHD and CD. Conclusion: Up till now, there is no conclusive evidence for a relationship between ADHD and CD. Therefore, it is not advised to perform routine screening of CD when assessing ADHD (and vice versa) or to implement gluten-free diet as a standard treatment in ADHD.

Factors influencing adherence to therapeutic recommendations made after diagnostic reassessment of medically unexplained symptoms in children and adolescents.

BACKGROUND: Medically unexplained symptoms (MUS) are common among children and adolescents and may be highly impairing. Even after long diagnostic and/or therapeutic trajectories, many of these children and their parents feel dissatisfied with the advice and therapies they were given. OBJECTIVES: After a 2-week hospitalisation for somatic and psychiatric reassessment, children and their families were given recommendations for further treatment. This study evaluates which of these recommendations were carried out (primary outcome measure) and which factors influenced the (non-)adherence to therapeutic advice. METHODS: Parents of 27 children aged 7-17 with impairing MUS took part in a structured telephone survey to assess adherence to and perceived effectiveness of therapeutic recommendations (cross-sectional study). Influencing factors were analysed retrospectively. RESULTS: Psychotherapy was recommended to all 27 patients and their families; 19 of them (70.4%) carried out this advice. When physiotherapy was recommended, adherence proved lower (6/22 children; 27.3%). No influencing factors were found to have a statistically significant correlation with adherence. Effect sizes may be indicative of clinically relevant influential factors, but should be considered cautiously. CONCLUSION: Results suggest that more efforts need to be made to ensure adherence to therapeutic recommendations. Known risk factors for non-adherence to treatments for chronic somatic disorders may not apply for children with somatoform disorders.

A file study of refugee children referred to specialized mental health care: from an individual diagnostic to an ecological perspective.

The past years have been characterized by a large refugee crisis across the globe. The exposure to preflight, flight, and resettlement stressors puts refugee children and their families at risk of developing emotional and behavioral disorders. A unique Western-based approach of mental health problems seems to be insufficient to address the complexity of interactions between individual vulnerabilities and more ecological surrounding systems. We looked into (1) the reasons for referral; and (2) the process diagnostic outcomes after ethnopsychiatric and psychological assessment. We conducted a thematic content analysis on 93 files of refugee children. The findings suggest that mental health care professionals need to hold into account the multiplicity and intertwining of ongoing challenges to the well-being of refugee children. The integration of a Western-based psychiatric assessment with a more ecologically based view can lead to a more culturally sensitive approach in refugee children and their families. This way, both under- and overdiagnosis of psychiatric disorders could be avoided to further optimalise mental health care in this population.

An Intervention Supporting the Mental Health of Children with a Refugee Background.

This contribution proposes an intervention methodology that provides improved access to and effectiveness of mental health care facilities in Brussels, Belgium, for children and their families with a refugee and migration background. Migration is a complex process that involves several potential risk factors, and referral to mental health facilities is often ineffective. Consequently, optimal developmental opportunities for refugee children are hampered. The intervention is underpinned by a broad-based contextual perspective that seeks to bring to the surface and tackles the many challenges faced by these families. It takes into account the unique developmental context of refugee children, as well as the interplay with broader systems.

The Impact of Idle Time in the Classroom: Differential Effects on Children With ADHD.

OBJECTIVE: Studies have identified an exacerbation of ADHD deficits under specific laboratory conditions. Less is known about the significance of such contextual factors in relation to everyday functioning in naturalistic settings. METHOD: This study investigated the differential impact of classroom "idle time"--periods when students are not actively engaged or waiting for a task--on the behavior of 31 children with ADHD (25 boys and 6 girls; aged 6-12 years) and 31 sex- and age-matched typically developing classmates, who were simultaneously observed in their normal classroom during two school days. RESULTS: Both groups experienced the same amount of idle time (12% of the time). During idle time, however, levels of hyperactivity and noisiness increased significantly more in children with ADHD than in their classmates (p < .05). CONCLUSION: Findings highlight the differential susceptibility of ADHD children to classroom idle time. Classroom interventions might consider targeting specifically these periods to reduce disruptive behavior in these children.

The impact of instructional context on classroom on-task behavior: a matched comparison of children with ADHD and non-ADHD classmates.

Classroom inattentiveness is an important reason for clinical referral of children with ADHD and a strong predictor of their educational achievement. This study investigates classroom on-task behavior of Flemish children with ADHD withdrawn from medication as a function of instructional context. Thirty-one pairs of children (one with ADHD and one age- and sex-matched control; 25 boys and 6 girls 6 to 12years of age) were observed in their classroom environment during two consecutive school days. On-task behavior (time on-task and on-task span) of ADHD and non-ADHD individuals was compared in different class contexts (i.e., different class structures and academic content types). Individualized teacher supervision was simultaneously assessed. Generalized estimation equation analyses showed that children with ADHD were significantly less on-task than controls during individual work and whole class group teaching, but not during small group work, and had significantly shorter on-task span during academic tasks (mathematics, language, and sciences) and instructional transitions between tasks, but not during music and arts. These effects persisted even after controlling for the higher levels of teacher supervision observed for ADHD pupils (7%) across all contexts (vs. 4% in controls). Findings suggest that despite receiving more overall teacher supervision, children with ADHD displayed lower levels of on-task behavior in settings that place high self-regulatory, information processing, and motivational demands on them. This finding may have initial implications for classroom interventions in this population.

Altered circadian profiles in attention-deficit/hyperactivity disorder: an integrative review and theoretical framework for future studies.

Disruptions in the sleep-wake cycle and the circadian system have been found in a wide range of psychiatric disorders and are generally correlated with clinical severity and diminished quality of life. Emerging evidence suggests similar disturbances may be found in attention-deficit/hyperactivity disorder (ADHD). Here we review the available literature on across the day fluctuations in ADHD-related processes in terms of; (i) time of day effects on behavior and activity; (ii) morningness-eveningness chronotypology; (iii) sleep/wake rhythms; and (iv) rhythmicity in neuroendocrine and neurophysiological responsiveness. On this basis, we propose a neurobiological framework to guide future study, which sees circadian effects in ADHD, along with other aspects of ADHD arousal-related deficits (e.g., cognitive energetic deficits), as being the result of dysregulated locus coeruleus function. Based on this perspective specific recommendations for future research are presented.

Time-of-day effects in arousal: disrupted diurnal cortisol profiles in children with ADHD.

BACKGROUND: Fluctuations in attention-deficit hyperactivity disorder (ADHD) symptoms related to regulatory deficits in arousal states are themselves characterized by circadian rhythms. Although cortisol is an important circadian arousal-related marker, studies focusing on across-the-day cortisol variations in ADHD are scarce. There is no study with multiple measurements to take into account interday and intraday variability. METHODS: Salivary cortisol was sampled five times a day (awakening, 30 min after awakening, noon, 4 p.m., 8 p.m.) across five consecutive days in 33 children with ADHD (22 with and 11 without oppositional defiant disorder; ODD) and 33 class- and sex-matched controls (aged 6-12). The cortisol awakening response (increase from awakening to 30 min after awakening) and the diurnal cortisol profile (across-the-day variations) were compared for ADHD with ODD (ADHD + ODD) and without ODD (ADHD) subgroups and the control group. RESULTS: The cortisol awakening response was not significantly different between groups. However, longitudinal analyses to evaluate cortisol profiles across the day revealed a significant Group × Time effect (p < .001). More specifically, compared to each other, the ADHD subgroup showed a flatter slope with relative morning hypo-arousal and evening hyperarousal, whereas the ADHD + ODD subgroup showed a steeper slope with relative morning hyperarousal and evening hypo-arousal (p < .001). CONCLUSIONS: Findings support time-related arousal disruptions in children with ADHD associated with the presence or absence of ODD comorbidity. We recommend research on cortisol in larger samples for a better understanding of arousal mechanisms involved in ADHD not only with and without ODD but also with other comorbidities which may have implications for timing of arousal-based treatments.

Diurnal variations in arousal: a naturalistic heart rate study in children with ADHD.

Previous studies suggest an altered circadian regulation of arousal in children with attention-deficit hyperactivity disorder (ADHD) as measured by activity, circadian preference, and sleep-wake patterns. Although heart rate is an important measure to evaluate arousal profiles, to date it is unknown whether 24-h heart rate patterns differentiate between children with and without ADHD. In this study, 24-h heart rate data were collected in 30 non-medicated children with ADHD (aged 6-11) and 30 sex-, class-, and age-matched normal controls in their naturalistic home and school setting, during 5 days. Simultaneously, 24-h activity patterns were registered. Confounding effects of demographic variables (e.g., age, sex, BMI, pubertal stage) and comorbid internalizing and externalizing problems on heart rate levels were additionally assessed. Longitudinal analysis showed that heart rate levels were overall higher in the ADHD group (p < 0.01)--with the largest effects during afternoon and night--in a model controlling for age. Other factors did not significantly contribute to variations in heart rate levels. Compared to controls, children with ADHD showed higher activity levels during daytime (especially early afternoon), but not during nighttime (p < 0.05). Post hoc analyses showed that environmental effects might influence daytime variations. Findings suggest an autonomic imbalance in children with ADHD as compared to controls, with higher heart rate levels in the ADHD group. Nighttime tachycardia in this group could not be explained by nighttime activity levels or comorbid externalizing/internalizing problems. Further research on autonomic functioning in ADHD is recommended because of the major impact of higher resting heart rate on health outcomes.

Endometriosis is associated with a decreased risk of pre-eclampsia.

BACKGROUND: We postulated that impaired endometrial differentiation in women with pelvic endometriosis predisposes for pre-eclampsia. METHODS: A retrospective case-control study set at the University of Ghent IVF centre. The incidence of pre-eclampsia and pregnancy-induced hypertension (PIH) following the clinical and/or laparoscopic diagnosis of endometriosis-associated infertility (case group; n = 245 pregnancies) was compared with the incidence of these obstetric complications in pregnancies following treatment for male-factor infertility (control group; n = 274 pregnancies). Pregnancy data were obtained by searching electronic databases and postal questionnaires. The case and control groups were matched for age, parity and multiple pregnancies. RESULTS: The incidence of pre-eclampsia was significantly lower in the case group (0.8%) when compared with control group (5.8%) (P = 0.002; odds ratio (OR) = 7.5, 95% confidence interval (CI): 1.7-33.3). Analysis of obstetric outcome in the subgroup of patients with laparoscopic data confirmed the lower risk of pre-eclampsia in the case (1.2%) versus control (7.4%) groups (P = 0.032; OR = 6.6, 95% CI: 1.2-37). PIH occurred in 3.5% and 8.7% of case and control pregnancies, respectively (P = 0.018; OR = 2.6, 95% CI: 1.2-6.0). The odds of developing pre-eclampsia were 5.67 times higher in the control group than in pregnancies following endometriosis-associated infertility. In multiple pregnancies, the odds of developing pre-eclampsia increased 1.93 times per additional child, with or without endometriosis. CONCLUSIONS: We found no evidence that endometriosis predisposes for pre-eclampsia. Instead, the risk of hypertensive disorder in pregnancy is significantly reduced in women with endometriosis-associated infertility.