Talk:Attention deficit hyperactivity disorder

ADHD- natural remedies

In reading over the information on ADHD treatments, I didn't find that there was much information on natural remedies or dietary restrictions. Here's some stuff I think would be helpful!

There is evidence supporting the use of nutritional supplements in helping to control ADHD, especially in young children. For example, supplements including omega-3 polyunsaturated fatty acid compounds and minerals have been found to improve ADHD symptoms.

While prescription drugs have been found to have positive effects on ADHD symptoms, there is also research supporting the use of nutritional supplements. While the findings have not been proven sufficient enough to draw generalized conclusions, they have shown that adding supplemental nutrients to an individual’s daily diet may indeed help with the symptoms associated with ADHD. Among the supplements tested are omega-3 fatty acid compounds (also known as fish oil), iron supplements, and zinc supplements. While these supplements have been researched, it is also important to consider the removal of certain components of a diet when treating the symptoms of ADHD. For example, because hyperactivity and issues with concentration are such a significant part of the problematic symptoms, sugar is often removed (or at least limited) when using natural remedies for such symptoms.

References

-- — Preceding unsigned comment added by Cevance (talk • contribs) 02:32, 9 March 2016‎ (UTC)

Wikipedia does not hype things that "may" work. There is either evidence that they are safe and effective enough, or not. Please read that source again. You are not representing it accurately. Also please avoid giving medical advice. You may want to read WP:MEDMOS. Jytdog (talk) 02:35, 9 March 2016 (UTC)

Intervention studies in an academic setting

A systematic review in 2015 looked at four groups of studies that measured the efficiency of non-medicinal treatment strategies, resulting from modification of the behavior in children within their school environments. I'm hoping that another editor can share their thoughts on the review. Richardson M, Moore DA, Gwernan-Jones R, Thompson-Coon J, Ukoumunne O, Rogers M, et al. Non-pharmacological interventions for attention-deficit/hyperactivity disorder (ADHD) delivered in school settings: systematic reviews of quantitative and qualitative research. Health Technol Assess 2015;19(45). http://www.journalslibrary.nihr.ac.uk/__data/assets/pdf_file/0011/146684/FullReport-hta19450.pdf

I'll leave it to another editor to decide whether to add this review to the references, or perhaps to the page itself. I believe the findings would fit in the environmental section, societal section, or in a subsection about intervention therapies. I'm happy to write a section on the findings of this review; just wanted to check with the ADHD page community before possibly stepping on anyone's toes. Thanks for the feedback! Zharris24 (talk) 05:18, 9 March 2016 (UTC)

that is a very high quality source. nice find. it basically says that "we don't know." it says effect sizes were small, outcomes were qualitative, and they cannot tell which intervention caused which outcome. the state of research is messy. Jytdog (talk) 05:46, 9 March 2016 (UTC)

Seminar

Lancet doi:10.1016/S0140-6736(15)00238-X JFW | T@lk 23:52, 19 March 2016 (UTC)

Gluten and ADHD

The following were added today:

At "Causes: Environment":

An association of ADHD with gluten intolerance, both celiac disease and non-celiac gluten sensitivity, has been found. ADHD may be the only symptom of these two diseases, even in absence of gastrointestinal symptoms.

and later a subsection under Management "Gluten-free diet" was created: People with undiagnosed celiac disease or non-celiac gluten sensitivity may develop ADHD, which may be the only symptoms in absence of gastrointestinal complaints. Gluten-free diet often improves them. In one study, the majority of patients (74%) chose to continue the gluten-free diet due to significant relief of their symptoms after six months of gluten withdrawal.

The Fasono source from 2015 is a) very clear about gluten-free being faddish, and b) is tentative on the gluten hypothesis: "Children with NCGS mainly have intestinal symptoms such as abdominal pain and chronic diarrhea without weight loss. Less frequently, they present with extraintestinal manifestations, including fatigue and attention-deficit disorders. Of particular interest is the relationship between NCGS and neurologic and neuropsychiatric disorders, including autism, schizophrenia, and peripheral neuropathy. However, it is not clear how gluten might contribute to these disorders." The older 2012 Jackson paper (which we don't need at all, since we have the Fasano review) is also tentative, noting " few studies have suggested that Attention Deficit Hyperactivity Disorder (ADHD) may be associated with gluten intolerance as well. A study measured ADHD symptoms in CD patients and found that these symptoms are “overrepresented” as compared to the general population. A 6-month gluten-free diet was reported to improved ADHD symptoms and the majority of patients (74%) in this report wanted to continue the gluten-free diet due to significant relief of their symptoms" And if you look at that clinical trial (PMID 17085630) it is 10 years old, and is a single arm study of people with celiac, looking for ADHD-like symptoms. The proposed content doesn't represent the sources and additionally appears to be UNDUE to me. Jytdog (talk) 12:48, 24 March 2016 (UTC)

It is certainly troubling that Schuppan is both an author of the (primary sourced) FasanoSapone2015 paper and an editor of the special issue which published it. Not to mention having a declared COI. I think we could afford to stick to the (almost secondary) source per wp:MEDRS. Note that Fasano is both reviewing and reviewed in that paper. It, however, does not present evidence to associate ADHD with GS, just with CD (per ref 34 to that paper). It does speculate that GS may be associated with ADHD, but does not present this as anything more than a possibility to be investigated. Given the well-documented connection between CD and B12 deficiency (particularly but not entirely before diagnosis) the whole question of how CD impacts neurology may be difficult to chase down, likely with multiple insults playing a role. We likely should give this some more time for the literature to shake out. LeadSongDog come howl! 16:32, 24 March 2016 (UTC)

Jytdog, I hope you're not trying to bias the information WP:NPOV.

• You said: "The Fasono source from 2015 is a) very clear about gluten-free being faddish," "Very clear" about gluten-free being faddish??? Just opposite! All paper is a complete review of current knowledge about non-celiac gluten sensitivity, a real health disorder that is not a "fad", and Fasano states:

Although there is clearly a fad component to the popularity of the GFD, there is also undisputable and increasing evidence for NCGS.

• You extracted from Fasano source: "Less frequently, they present with extraintestinal manifestations, including fatigue and attention-deficit disorders." Children People who develop ADHD symptoms because of non-celiac gluten sensitivity, whether a majority or a minority, have no right to cure or improve...? There is no reason to hide this information. WP:NPOV

• You said: "And if you look at that clinical trial (PMID 17085630) it is 10 years old, and is a single arm study of people with celiac, looking for ADHD-like symptoms." Gluten-free diet resolves or improves digestive and extraintestinal symptoms, and associated diseases, now and 10, 20, 30... years ago. The cause of celiac disease remains the same: gluten intolerance. Gluten-free diet is in fact the only available treatment. I cited this because of is included in a secondary source, per WP:MEDRS. But this is not a single study. There are other reports:

Front Hum Neurosci. 2013 Jan 4;6:344. doi: 10.3389/fnhum.2012.00344. eCollection 2012. Gluten- and casein-free dietary intervention for autism spectrum conditions. Whiteley P, Shattock P, Knivsberg AM, Seim A, Reichelt KL, Todd L, Carr K, Hooper M PMID 23316152

Additional studies incorporating the exclusion of dietary gluten and casein in related conditions such as attention-deficit hyperactivity disorder (ADHD) have also noted positive effects on symptoms (Pelsser et al., 2011) particularly in cases of overlapping CD (Niederhofer, 2011) where both somatic and psychological presentation were affected. Combined however, such co-morbidities are not thought to be able to account for all cases of success despite no commonplace screening for such potential issues in ASCs and the possibility of non-CD mediated sensitivities (Biesiekierski et al., 2011).

- (Pelsser et al., 2011) Lancet. 2011 Feb 5;377(9764):494-503. doi: 10.1016/S0140-6736(10)62227-1. Effects of a restricted elimination diet on the behaviour of children with attention-deficit hyperactivity disorder (INCA study): a randomised controlled trial. Pelsser LM1, Frankena K, Toorman J, Savelkoul HF, Dubois AE, Pereira RR, Haagen TA, Rommelse NN, Buitelaar JK.

- (Niederhofer, 2011) Prim Care Companion CNS Disord. 2011;13(3). pii: PCC.10br01104. doi: 10.4088/PCC.10br01104. Association of attention-deficit/hyperactivity disorder and celiac disease: a brief report. Niederhofer H.

Prim Care Companion CNS Disord. 2011;13(3). pii: PCC.10br01104. doi: 10.4088/PCC.10br01104. Association of attention-deficit/hyperactivity disorder and celiac disease: a brief report. Niederhofer H. PMID 21977364

Conclusions: Celiac disease is markedly overrepresented among patients presenting with ADHD. A gluten-free diet significantly improved ADHD symptoms in patients with celiac disease in this study. The results further suggest that celiac disease should be included in the ADHD symptom checklist.

BMC Pediatr. 2011 May 27;11:46. doi: 10.1186/1471-2431-11-46. Compliant gluten-free children with celiac disease: an evaluation of psychological distress. Mazzone L, Reale L, Spina M, Guarnera M, Lionetti E, Martorana S, Mazzone D PMID 21619651

Children with celiac disease can also suffer from neurological and psychological disorders, including headaches, attention-deficit/hyperactivity disorder (ADHD), learning and tic disorders, depression and anxiety, mostly before any dietary treatment [12-15].

12. Lionetti E, Francavilla R, Maiuri L, Ruggieri M, Spina M, Pavone P, Francavilla T, Magistà AM, Pavone L. Headache in pediatric patients with celiac disease and its prevalence as a diagnostic clue. Journal of Pediatric Gastroenterology and Nutrition. 2009;49(2):202–7. doi: 10.1097/MPG.0b013e31818f6389. PMID 19543115

13. Pynnönen P, Isometsä E, Aronen E, Verkasalo MA, Savilahti E, Aalberg VA. Mental disorders in adolescents with celiac disease. Psychosomatics. 2004;45(4):325–35. doi: 10.1176/appi.psy.45.4.325. PMID 15232047

14. Pynnönen PA, Isometsä ET, Verkasalo MA, Kähkönen SA, Sipilä I, Savilahti E, Aalberg VA. Gluten-free diet may alleviate depressive and behavioural symptoms in adolescents with coeliac disease: a prospective follow-up case-series study. BMC Psychiatry. 2005;5:14. doi: 10.1186/1471-244X-5-14. [PMC free article] PMID 15774013

Niederhofer H, Pittschieler K. A preliminary investigation of ADHD symptoms in persons with celiac disease. Atten Disord. 2006;10:200–4. doi: 10.1177/1087054706292109. PMID 17085630

Pediatrics. 2004 Jun;113(6):1672-6. Range of neurologic disorders in patients with celiac disease. Zelnik N, Pacht A, Obeid R, Lerner A. PMID 15173490

CONCLUSION: This study suggests that the variability of neurologic disorders that occur in CD is broader than previously reported and includes "softer" and more common neurologic disorders, such as chronic headache, developmental delay, hypotonia, and learning disorders or ADHD. Future longitudinal prospective studies might better define the full range of these neurologic disorders and their clinical response to a gluten-free diet.

Two interesting papers:

Child Adolesc Psychiatr Clin N Am. 2014 Oct;23(4):937-53. doi: 10.1016/j.chc.2014.05.010. Epub 2014 Aug 10. Restriction and elimination diets in ADHD treatment. Nigg JT, Holton K PMID 25220094

ELIMINATION DIETS AND HEALTH The focus of elimination diets is to remove specific foods from the diet in an effort to eliminate potential allergens that occur naturally in food (eg, eggs, wheat, dairy, soy) or artificial ingredients that may have allergenic or even toxicant effects (eg, synthetic food additives: artificial colors, flavors, sweeteners, as well as flavor enhancers [like monosodium glutamate (MSG)] and preservatives). These diets are used to attempt to diagnose and treat food allergies and intolerances. (...) When putting together both studies of restriction/elimination diets generally and studies of food color elimination specifically, effects sizes across the best studies therefore appear to range from d = 0.2 to d = 0.4 depending on study selection, with the possibility that effects are somewhat larger in children with ADHD. However, the finding of larger mean symptom changes in children with ADHD is difficult to interpret, because those children by definition have more extreme symptom scores and therefore less restriction of range in their scores in response to intervention. In addition, if food colors are not the main culprit in dietary effects, then challenge studies of food colors will underestimate the effects of an elimination diet. Carter and colleagues47 challenged children who had responded to an elimination diet with foods to identify what caused their symptoms to worsen. During these challenges, a wide range of foods provoked reactions, including typical allergenic foods (wheat, eggs, milk, cheese), chocolate, and additive-containing foods. Only a small minority of children seemed to react primarily to artificial colorings.

Nutr Res Rev. 2014 Dec;27(2):199-214. doi: 10.1017/S0954422414000110. Epub 2014 Jul 8. Autism and nutrition: the role of the gut-brain axis. van De Sande MM, van Buul VJ, Brouns FJ. PMID 21296237

Recently, Sabra et al.(104) hypothesised that food allergy is the pivotal causative factor that produces lesions in the ileum that consist of enlarged lymphoid nodules containing large collections of lymphocytes in the GI lymphoid tissues adjacent to Peyer’s patches. These GI lesions would allow the entry of food antigens across the inflamed mucosa of the bowel and elicit an inflammatory response in the GI tract(104). They found LNH, reactive lymphoid follicular hyperplasia and chronic inflammation in twelve children with attention-deficit/hyperactivity disorder, autism, anorexia and/or migraine. Th1-associated cytokines were found to be decreased compared with control values, which, together with a predominance of CD4þ cells, support an immunological basis for non-IgEmediated food allergy (NFA) in this group(104). (...) Consequently, there have been many reports on the role of a GFCF diet on alleviating several symptoms of autistic individuals(19,110 – 116) (however, not all of sufficient methodological quality; see below). Significant improvements have been noted within psychological and behavioural categories in vocal and non-vocal communication, attention and concentration, episodes of aggressiveness, affection, motor skills, sleeping patterns, displaying of routines and rituals, anxiety, empathy and responses to learning(19,111,112,115,116). Moreover, reintroduction of dietary gluten elicited a worsening of behaviours in areas of hyperactivity and impulsivity, stereotyped behaviours, aggression and language and communication skills(19). A slight initial worsening in behaviour after introduction of the GFCF diet was also noted, which was suggested to be comparable with the withdrawal behaviours exhibited by opioid addicts on the removal of opioids(19). Changes in physical and physiological areas were measured in some studies as well. One patient showed abnormal peptides not found in controls, including b-casomorphin (BCM), a-gliadin, dermorphin, deltorphin I and II, and morphine-modulating neuropeptide(117). Some of these have also been observed in other studies(57,112,118).

Anyway, Jytdog and LeadSongDog, I agree to take another approach, include a text much shorter and eliminating the mention in the treatment section.

Best regards. --BallenaBlanca (talk) 19:25, 24 March 2016 (UTC)

Ballena. Please strike your first sentence, and then I will be happy to reply. Jytdog (talk) 20:44, 24 March 2016 (UTC)

Sorry, Jytdog. It was not my intention to offend you. I've already done it. Now, let's talk. You reverted once again... Best regards. --BallenaBlanca (talk) 22:19, 24 March 2016 (UTC)

Great. Now. What I actually wrote was "The Fasono source from 2015 is a) very clear about gluten-free being faddish, and b) is tentative on the gluten hypothesis:." I left off, "with regard to the relationship between gluten and ADHD". Sorry for eliding that. Jytdog (talk) 22:32, 24 March 2016 (UTC)

FWIW, a positive correlation between celiac disease or gluten intolerance and ADHD could be mediated entirely at a genetic level, in which case gluten itself has nothing to do with ADHD in otherwise healthy individuals. All that association suggests is that celiac disease/gluten intolerance and ADHD are comorbid disorders. I doubt gluten itself has anything to do with ADHD pathology in individuals without a gluten sensitivity, especially because this unfiltered search returned nothing. Seppi333 (Insert 2¢) 22:43, 24 March 2016 (UTC)

Jytdog, you are misinterpreting. You say that Fasano is "very clear about gluten-free being faddish ... is tentative on the gluten hypothesis ... with regard to the relationship between gluten and ADHD". If you read the rest of the paper, you'll see that he doesn't say nothing like this! Fasano says "However, it is not clear how gluten might contribute to these (neurological and psychiatric) disorders." because actually we don't know the exact pathogenesis of non-celiac gluten sensitivity: besides gluten, other proteins present in gluten-containing cereals (ATIs) seem to play a role in the development of symptoms, both digestive and extraintestinal symptoms:

Pathogenesis. Researchers are investigating the pathogenesis of NCGS; this disorder only recently has become a subject of systematic research. Our level of knowledge about NCGS pathogenesis is comparable with what was known about celiac disease more than 20 years ago. Gluten is the undisputable cause of celiac disease and therefore it was assumed that the same applied to NCGS. However, besides gluten, wheat, barley, rye, and their derivatives contain other components that induce symptoms, including amylasetrypsin inhibitors (ATIs) and FODMAPs. FODMAPs cause mild wheat intolerance at most, limited to intestinal symptoms, so we can exclude them from further discussion in the context of NCGS. Patients with NCGS resolve symptoms after they eliminate glutencontaining grains, despite continuing to ingest FODMAPs from other sources. Children with NCGS mainly have intestinal symptoms such as abdominal pain and chronic diarrhea without weight loss. Less frequently, they present with extraintestinal manifestations, including fatigue and attention-deficit disorders.25 Of particular interest is the relationship between NCGS and neurologic and neuropsychiatric disorders, including autism, schizophrenia, and peripheral neuropathy.26–28 However, it is not clear how gluten might contribute to these disorders. (...) more evidence is needed about the mechanisms leading to the improvement of diseases affecting the nervous system as well as other organs after dietary elimination of gluten or nongluten proteins. (...) there is growing evidence that other proteins that are unique to gluten-containing cereals can elicit an innate immune response that leads to NCGS, raising a nomenclature issue. For this reason, wheat sensitivity, rather than gluten sensitivity, seems to be a more appropriate term, keeping in mind that other gluten-containing grains such as barley and rye also can trigger the symptoms.

ATIs are proteins that induce an immune response, not a "fad". And they are also present in commercial gluten...:

ATIs are plant-derived proteins that inhibit enzymes of common parasites, such as mealworms and mealbugs, in wheat. (...) Studies of biopsy specimens from patients with celiac disease showed that ATIs increase the gluten-specific T-cell response.49 Therefore, ATIs could be the long-sought inducers of innate immunity in patients with celiac disease or NCGS. Importantly, ATIs are present in commercial gluten and resist proteolytic digestion, such as by the gastric and enteric proteases pepsin and trypsin, maintaining the ability to activate TLR4 throughout oral ingestion and intestinal passage. (...) ATI species, approximately 120–150 amino acids long, in modern wheat, with a variant primary sequence but a conserved secondary structure.51

...and some people with celiac disease / non-celiac gluten sensitivity may develop ADHD symptoms which often improve with a gluten-free diet (gluten-free diet removes all gluten-containing cereals and therefore removes gluten and ATIs). This is a reality that we must state, best if we add that "the underlying mechanism is not clear"; as we state, for example, that "Exposure to the organophosphate insecticides chlorpyrifos and dialkyl phosphate is associated with an increased risk; however, the evidence is not conclusive.[82]" or "Some children may react negatively to food dyes or preservatives.[87] It is possible that certain food coloring may act as a trigger in those who are genetically predisposed but the evidence is weak.[88]"

Best regards. --BallenaBlanca (talk) 01:25, 25 March 2016 (UTC)

Your comments here are far too long. The Fasano article is extremely clear that there is faddism around gluten and it is tentative with regard to connections between gluten and ADHD. Yes it does say that some people with celiac non-celiac gluten sensitivity have ADHD-like symptoms. It does not discuss the very old, single arm trial at all. We rely on recent reviews per WP:MEDRS and there is no reason to mention the older review nor to provide any detail about that small and quite useless old trial. Jytdog (talk) 01:33, 25 March 2016 (UTC) (correct error Jytdog (talk) 02:32, 25 March 2016 (UTC))

Link to download full text of Fasano source: Fasano A, Sapone A, Zevallos V, Schuppan D (May 2015). "Nonceliac gluten sensitivity". Gastroenterology (Impact Factor: 16.72). 01/2015; 148(6). DOI: 10.1053/j.gastro.2014.12.049 - RESEARCHGATE

I have read the whole source. I would not be writing here, if I had not. Jytdog (talk) 02:26, 25 March 2016 (UTC)

Don'worry, I've noticed that you have the paper. The link is so that other users can review it. Best regards. --BallenaBlanca (talk) 02:42, 25 March 2016 (UTC)

(edit conflict) The only other source that seems possibly relevant and MEDRS compliant that you introduced was PMID 25220094; I just read that too and it only talks about gluten as a paradigmatic elimination diet. It focuses on diets eliminating food colorings etc as possible ADHD treatments and gives no attention to gluten after the brief description I just mentioned. It is a review on elimination diets for ADHD and if those authors thought the gluten-elimination approach was noteworthy or significant for ADHD, they had every opportunity to discuss it, and they didn't. This is exactly what we rely on MEDRS-sources to do for us. Otherwise the sources you mention above are not MEDRS compliant. Jytdog (talk) 02:44, 25 March 2016 (UTC)

The conclusions of this source are: "The literature clearly demonstrates that a minority of children with ADHD will benefit from an elimination diet. Research funders, scientists, and clinicians would do well to re-invigorate investigation of this intervention, while avoiding both excessive skepticism (clearly, it may work for some), and excess optimism (it probably only works for a minority) ... dietary intervention for ADHD was abandoned too quickly in North America. Although it is likely that only a minority of children with ADHD will respond to dietary intervention, the evidence persistently suggests that for some children such intervention can be quite effective. ". Diets are not profitable for pharmaceutical companies....

I did not say that a gluten-free diet may work for everyone, just for one subgroup (people with CD or NCGS), and it is documented although they are few studies (dietary intervention for ADHD was abandoned too quickly...). And I repeat: this minority of people who develop ADHD symptoms because of celiac disease / non-celiac gluten sensitivity have no right to cure or improve, or to know this information...? Are "minorities" have no right?

Elimination diets reinforce the idea that wheat ("gluten and ATIs") may be involved. Also, very often in gluten-free diet is not enough to remove only gluten, more food must be removed, especially in cases with long delays in diagnosis (which is usual, there often are delays of many years, including children). Intestinal permeability and mucosal damage caused by gluten are responsible for the appearance of more food allergies and intolerances, which are often reversible after months or years of strict GFD, and avoidable with an early diagnosis. But researchers are badly lost and disoriented, generally uninterested or they do not get money to fund the studies (diets are not profitable for pharmaceutical companies).

Authors of this paper PMID 25220094, when summarizing the results, talk about of all elimination diets in general terms.

The focus of elimination diets is to remove specific foods from the diet in an effort to eliminate potential allergens that occur naturally in food (eg, eggs, wheat, dairy, soy) or artificial ingredients that may have allergenic or even toxicant effects (eg, synthetic food additives: artificial colors, flavors, sweeteners, as well as flavor enhancers [like monosodium glutamate (MSG)] and preservatives). These diets are used to attempt to diagnose and treat food allergies and intolerances.

Food elimination diets vary in their specific content, but take 3 main forms. A single food exclusion diet excludes one suspected food, such as eggs. A multifood exclusion diet, such as the 6-food elimination diet, eliminates the most common food allergens: cow-milk protein, soy, wheat, eggs, peanuts, and seafood. A “few foods diet” (also called an oligoantigenic diet) restricts a person’s diet to only a few less commonly consumed foods (eg, lamb/venison, quinoa/rice, pear, and others with low allergenic potential). (...)

Other specific elimination diets exist, such as a gluten-free diet and the Kaiser Per-manente (or Feingold) diet. The gluten-free diet is currently the only successful treatment for patients with celiac disease15 and is also being used to treat nonceliac gluten sensitivity.16 Gluten is the protein found in wheat, rye, and barley, and thus, any item in the diet containing these grains (including some food additives) must be removed. A gluten and casein-free diet is also being tested in autism.17 (...)

Overall, for children presenting for ADHD treatment with no obvious gastrointestinal symptoms or strong prior evidence of a dietary effect, a strict elimination diet may have a 10% to 30% chance of providing a true effect detectable on a double-blind measurement, but this estimate is limited by very small samples and widely varying methods. The best estimate on the small literature is about a 25% rate of at least some symptom improvement. For some children, perhaps a minority of 10% of children with ADHD, response can include a full remission of symptoms equivalent to a successful medication trial. In short, the literature suggests that an elimination diet should be considered a possible treatment for ADHD, but one that will work partially or fully, and only in a potentially small subset of children. (...)

With that said, (1) many parents remain interested in dietary intervention, (2) the literature suggests that some children may benefit (a trial is not senseless), and (3), clinicians need some idea what the family would be getting into if they attempt a restriction diet. Therefore, a brief presentation of clinical considerations if such an intervention is going to be pursued follows. (...)

A major recommendation coming out of this review, echoing prior reviews (see Table 1), is that dietary intervention for ADHD was abandoned too quickly in North America. Although it is likely that only a minority of children with ADHD will respond to dietary intervention, the evidence persistently suggests that for some children such intervention can be quite effective. Thus, where should the field go to develop and realize this possibility? Several additional future study and design considerations and suggestions were offered by Stevenson and colleagues.46 The present authors highlight selected recommendations of their own here.

Best regards. --BallenaBlanca (talk) 11:05, 25 March 2016 (UTC)

Could we summarize this as "A gluten free diet in those with CD and ADHD may improve the symptoms of both."? Doc James (talk · contribs · email) 13:27, 25 March 2016 (UTC)

I agree, Doc James. Best regards. --BallenaBlanca (talk) 14:16, 25 March 2016 (UTC)

User:Doc James this is an article on ADHD. That summary goes beyond what the source says; this whole "may improve" thing is the language that advocates throughout Wikipedia try to use to get fringe-y treatments into the encyclopedia. There is no clear biological connection between gluten and ADHD (like there is no link between say magnetic bracelets and cancer) and the clinical evidence is scant. As I noted above the most recent review on dietary interventions for ADHD (PMID 25220094) doesn't mention gluten restriction as a treatment for ADHD at all. Jytdog (talk)

Not as a treatment for all cases, of course. Nobody is saying that. This is to state objectively that GFD improves ADHD symptoms in celiac patients.

It would be good to add, in addition to GFD in CD, a brief mention to elimination diets, supported by that source, including it on a "Diet" sub-section. Wording from these two paragraphs: "Food elimination diets vary in their specific content, but take 3 main forms. A single food exclusion diet excludes one suspected food, such as eggs. A multifood exclusion diet, such as the 6-food elimination diet, eliminates the most common food allergens: cow-milk protein, soy, wheat, eggs, peanuts, and seafood. A “few foods diet” (also called an oligoantigenic diet) restricts a person’s diet to only a few less commonly consumed foods (eg, lamb/venison, quinoa/rice, pear, and others with low allergenic potential). The “few foods diet” must be overseen by a properly qualified professional (eg, dietitian) to avoid nutritional deficiency, but is effective at identifying multiple food allergies in an individual.11 Much of the use of these diets in the medical literature is targeted at single specific food allergies (eg, cow’s milk12 or physical symptoms thought to potentially be related to food allergies, such as esophagitis).13" .... "Referral to an immunologist who can conduct skin prick allergy testing may also be beneficial, but dietary response may occur even with a negative skin prick test, if the response is due to a food intolerance rather than to an allergy. It remains unclear whether the presence of food allergy symptoms or allergy skin prick findings increase the likelihood that ADHD symptoms will respond to an elimination diet." ..... " The literature clearly demonstrates that a minority of children with ADHD will benefit from an elimination diet. Research funders, scientists, and clinicians would do well to re-invigorate investigation of this intervention, while avoiding both excessive skepticism (clearly, it may work for some), and excess optimism (it probably only works for a minority). "

Best regards. --BallenaBlanca (talk) 20:41, 25 March 2016 (UTC)

There is insufficient sourcing to justify including discussion of a gluten-free diet in this article. Jytdog (talk) 22:02, 25 March 2016 (UTC)

Ref says "an elimination diet produces a small but reliable aggregate effect"[1] The ref comments on celiacs but makes no claim that it improves ADHD symptoms I agree. Doc James (talk · contribs · email) 09:57, 26 March 2016 (UTC)

Well, there's no doubt about this reference PMID 25220094, we all agree, and I will include two brief sentences, without talking about gluten, nor gluten-free diet. I respect the discussion.

Regarding the mention to gluten-free diet in celiacs, which is the issue of this discussion, Doc James, you said: Could we summarize this as "A gluten free diet in those with CD and ADHD may improve the symptoms of both."? supported by these two other sources. I agree to eliminate Fasano's source. What do you think?

Best regards. --BallenaBlanca (talk) 00:41, 27 March 2016 (UTC)

With which ref to support again? Doc James (talk · contribs · email) 11:16, 27 March 2016 (UTC)

We have another ref that says elimination diets are not supported. So obviously they are controversial. Balanced the two. Doc James (talk · contribs · email) 11:14, 27 March 2016 (UTC)

I agree. I have adjusted a bit.

With which ref to support again? This reference is perfectly valid PMID 21877216. As we have seen above, in the literature are a few studies on the improvement of ADHD symptoms with a gluten-free diet in people previously undiagnosed of CD. This article extracts the results of one of them, but is not the only one. We can write, as is customary in these cases, something like this: A few studies in patients with undiagnosed celiac disease showed an improvement of symptoms of ADHD when starting a gluten-free diet.''

Neurologic and psychiatric manifestations of celiac disease and gluten sensitivity. PMID 21877216

Attention Deficit-Hyperactivity Disorder (ADHD). A few studies have suggested that Attention Deficit Hyperactivity Disorder (ADHD) may be associated with gluten intolerance as well. A study measured ADHD symptoms in CD patients and found that these symptoms are “overrepresented” as compared to the general population. A 6-month gluten-free diet was reported to improved ADHD symptoms and the majority of patients (74%) in this report wanted to continue the gluten-free diet due to significant relief of their symptoms

Best regards. --BallenaBlanca (talk) 18:08, 27 March 2016 (UTC)

Break

Hi, Doc James. Perhaps you didn't read my last message. You proposed summarize this as "A gluten free diet in those with CD and ADHD may improve the symptoms of both." and I proposed something like this, to adjust and be more precise: A few studies in patients with an undiagnosed celiac disease showed an improvement of symptoms of ADHD when starting a gluten-free diet. Which of the two we choose?

The Psychiatric Quarterly is a peer-reviewed medical journal that was established in 1915, with an impact factor of 1.26 (5-year impact: 1.39).

Best regards. --BallenaBlanca (talk) 10:01, 3 April 2016 (UTC)

Added. Doc James (talk · contribs · email) 14:16, 3 April 2016 (UTC)

I've gotten the full paper of the newly added source PMID 26825336. It is a good source, published on Journal of Attention Disorders (current impact factor of 3.78). I will expand, supported by this source, and I will try to be as brief as possible. The text I will add is on the same line that the text has been discussed and approved above, that led to the inclusion of this text by Doc James: [2] (There is no clear relationship betwen ADHD and CD, but is not incompatible with the fact that CD patients with ADHD improve with GFD). I hope you agree and I wait your opinions. Best regards. --BallenaBlanca (talk) 10:38, 13 April 2016 (UTC)

Have adjusted it some. Let me know what you think. Remember to use "person with ADHD" rather than "ADHD patient" per the WP:MEDMOS.Doc James (talk · contribs · email) 19:09, 13 April 2016 (UTC)

Remember to use "person with ADHD" Oops...! Sorry! I will remember.

I like the adjustments you made, minus the last sentence: "People with ADHD and a broad range of physical symptoms should be tested. [158]" This implies that people with CD and ADHD have always a large number of other symptoms. The meaning is very different. The authors say literally: "Therefore, it is recommended for clinicians to assess a broad range of physical symptoms, in addition to typical neuropsychiatric symptoms, when evaluating patients with ADHD" because they previously explained the wide variety of symptoms (digestive and/or extra-digestive) that can present CD and make it difficult to identify. What it means is that physicians have to evaluate a wide range of symptoms, because the presence of any of them (perhaps only one, or two, or more... all is possible) may be the track to identify an undiagnosed CD. I realize that my previous text was confused, wanting to do so shortly.

It is clear that it is better to add a clarification, for everyone can understand it, without reading the entire reference, because out of context it is confusing.

I will adjust. Tell me if you like the result.

Best regards. --BallenaBlanca (talk) 21:10, 13 April 2016 (UTC)

The exact symptoms of celiacs belongs in the celiac article IMO as those symptoms are complicated. How about "In people with ADHD, those with any of a range of physical symptoms should be tested to identifying unrecognized celiac disease"? Doc James (talk · contribs · email) 12:47, 14 April 2016 (UTC)

People with symptoms of any mental health problem should always see their PCP to rule out likely physical ailments first. Celiacs is not unique in having some overlapping symptoms with ADHD and it's far from the most common. It not in the top 5. This reads like doctors have no idea ADHD symptoms could be caused by something else. We can't/shouldn't attempt to address every other issue that might present like ADHD and if we're going to mention some things that should be ruled out first, it should be the most common: seasonal allergies, asthma hearing or vision disorders, anemia, hashimotos/thyroid issues, tonsil/adenoid issues, sleep apnea and other sleep disorders, brain injury, elevated lead levels... and that's not even mentioning things like learning disabilities, other mental illnesses, and having crappy parents. If your pediatrician isn't ruling out other likely possibilities before officially diagnosing your kid with anything, you need a new pediatrician. As far as celiacs goes, it would encompassed with due weight in sentence like, "doctors should always rule out potential physiological explanations for attentional issues as part of a thorough ADHD evaluation." More sources talking about common things to rule out in patients with ADHD symptoms that don't mention celiacs: PermStrump(talk) 15:02, 14 April 2016 (UTC)

Hi, Permstrump. Your comments are very interesting and you are quite right. There is already a Differential diagnosis section which mentions most of the diseases that you are listing Attention_deficit_hyperactivity_disorder#Differential_diagnosis but I agree your observation: "doctors should always rule out potential physiological explanations for attentional issues as part of a thorough ADHD evaluation." IMO, this sentence should be on first place in the Diagnosis section, because it must be the first step, prior to psychiatric evaluation and ADHD diagnosis, searching a good source to support it. What do you think?

In the case of the section Diet, the objetive is to reflect the results of the studies with neutrality, explaining all conclusions. Perhaps the best thing is to modify a little again, to reflect what the authors mean in other words, compatible with the existence of a differential diagnosis section. I will do it. Let me know if you agree.

If your pediatrician isn't ruling out other likely possibilities before officially diagnosing your kid with anything, you need a new pediatrician. It could not have said it better! How right you are! And not only pediatrician, ADHD affects both children and adults.

Best regards. --BallenaBlanca (talk) 18:09, 14 April 2016 (UTC)

Doc James thanked me by this edit [3], reverted by Garzfoth [4] "Uh, this is even more incorrect and misleading... " I don't understand why this is "even more incorrect and misleading". It seems that the problem is to say that celiac disease "may present with mild or absent gastrointestinal complaints". Currently, it has changed the understanding of the presentation of CD. Non-classical CD presentation (with mild or absent gastrointestinal symptoms and extra-intestinal manifestations) is more common than classical presentation (with malabsorption and chronic diarrhea). Really, is even more adjusted to say that often present with mild or even absent gastrointestinal symptoms. Let's see two sources (NOTE: Non-classical and atypical refer to the same presentation and are interchangeably. Also, classical and typical are synonymous):

World Gastroenterology Organisation Global Guidelines on Celiac Disease

Many patients with CD have few symptoms or present atypically, whereas a minority of patients have malabsorption (classical CD).

Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology

Traditionally patients with CD presented with malabsorption dominated by diarrhoea, steatorrhoea, weight loss or failure to thrive (‘classical CD’),7 but over time the proportion of newly diagnosed patients with malabsorptive symptoms has decreased,31 and ‘non-classical CD’7 and even asymptomatic CD have gained prominence. Newly diagnosed patients with CD can present with a wide range of symptoms and signs, including anaemia,32 vague abdominal symptoms (often similar to irritable bowel syndrome (IBS)33), neuropathy,34 ,35 ataxia,36 depression,37 short stature,38 osteomalacia and osteoporosis,39 liver disease,40 adverse pregnancy outcomes41 and lymphoma.42

And let's see part of the text of the source used in ADHD. Really, the text currently included is very summarized, as there is much that can be written about it:

Untreated, CD has a wide range of clinical presentations. The “classical CD type” presents with mostly gastrointestinal symptoms such as abdominal pain, distension, chronic diarrhea, or failure to thrive. The “non-classic CD type” is characterized by fewer or no gastrointestinal symptoms and presents with extra-intestinal manifestations, such as neurologic, dermatologic, hematologic, endocrinologic, reproductive, renal, psychiatric, skeletal, and liver involvement (Celiloğlu, Karabiber, & Selimoğlu, 2011). The “asymptomatic or silent CD type” can present with no clinical symptoms and only positive serology (Bai et al., 2013). ...

Neuropsychiatric Symptoms in CD

Research on neuropsychiatric symptoms in patients with CD report age-related differences. In adult patients with CD, ataxia, epilepsy, peripheral neuropathy, inflammatory myopathies, myelopathies, headache, gluten encephalopathy, white matter abnormalities, anxiety disorders, depressive and mood disorders, ADHD, autism spectrum disorders, and schizophrenia have been reported (Jackson, Eaton, Cascella, Fasano, & Kelly, 2012). In children with CD, however, the risk of developing neuropsychiatric disturbances is only 2.6% (compared with 26% in adults; Ruggieri et al., 2008). This discrepancy may be due to shorter disease duration in children, earlier elimination of gluten from the diet, stricter adherence to a diet, or a different susceptibility to immune-mediated disorders (Lionetti et al., 2010; Ruggieri et al., 2008).

Discussion

ADHD-Like Behavior and CD

Based on this review, there is no conclusive evidence for a relationship between ADHD and CD. However, attention difficulties, distractibility, chronic fatigue, and headache have been observed in patients with CD, especially prior to treatment or when noncompliant to GFD (Terrone et al., 2013). Newly diagnosed children with CD often complained of “aches and pains,” “easily tired,” “easily distracted,” and “trouble concentrating.” After 1 year of GFD treatment, scores on these items were reduced and remained low in GFD-compliant children (Terrone et al., 2013). Also in newly diagnosed adults with CD, a significant improvement in cognitive functioning, particularly verbal fluency, attention, and motor function, is noted after a 12-month adherence to GFD (Lichtwark et al., 2014). Thus, it is possible that in untreated patients with CD, neurologic symptoms such as chronic fatigue, inattention, pain, and headache could predispose patients to ADHD-like behavior (mainly symptoms of inattentive type), which may be alleviated after GFD treatment.

Possible Mechanisms

Possible mechanisms underpinning the relation between attention/learning problems and CD point to accumulative effects of multiple effects, including both nutritional and immunologic/inflammatory factors. However, more indirect factors, related to nonspecific effects of chronic disease, cannot be ruled out (Zelnik et al., 2004). With respect to nutritional factors, micronutrient deficiencies and anemia are frequently seen in untreated patients with CD (Kupper, 2005; Wierdsma, van Bokhorst-de van der Schueren, Berkenpas, Mulder, & van Bodegraven, 2013). These factors may also play a role in causing ADHD-like behavior. However, when studying iron and zinc deficiencies in patients with ADHD, results remained inconclusive and needed further elaboration (for a review, see Millichap & Yee, 2012). There is emerging evidence that immunological mechanisms may contribute to ADHD development and manifestation (Verlaet, Noriega, Hermans, & Savelkoul, 2014). CD may induce an immune dysregulation in the gut, leading to chronic inflammation, which on its turn may be the cause for developing ADHD-like symptoms (Esparham, Evans, Wagner, & Drisko, 2014). Studies on the brain level point to the possible implication of serotonergic dysfunction in developing neuropsychiatric disorders in CD. More specifically, these studies refer to an impaired availability of tryptophan and decreased serotonin and dopamine metabolite concentrations (Hernanz & Polanco, 1991; Jackson et al., 2012; Pynnönen et al., 2005). Neuroimaging studies show structural and functional brain deficits in adult patients with CD. Structural deficits include bilateral decrease in cortical gray matter and caudate nuclei volumes (Bilgic et al., 2013), bilateral decrease in cerebellar gray matter, and smaller volume in multiple cortical regions (Currie et al., 2012). Functional deficits include a hypoperfusion of cerebral regions, primarily in the frontal cortex in untreated adult patients with CD, but not in treated patients (Addolorato et al., 2004; Usai et al., 2004). Such brain abnormalities may induce problems in high-cognitive functions such as attention span. Further research is however needed to confirm this hypothesis. To our knowledge, there are no studies on structural and functional brain deficits in pediatric patients with CD. A final hypothesis relates to increased oxidative stress that has been described in both ADHD (Lopresti, 2015) and CD (Stojiljković et al., 2009). Therefore, oxidative stress may represent a possible mediator in the development of ADHDlike behavior in CD patients. However, it remains uncertain whether oxidative stress itself contributes to the development or exacerbation of ADHD symptoms or whether it is the result of environmental factors (Lopresti, 2015). Further empirical studies are needed to understand the mechanisms underlying the potential association between ADHD, ADHD-like behavior, and CD.

Clinical Implications

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 GFD as a standard treatment in ADHD. Nevertheless, the possibility of untreated CD predisposing to ADHD-like behavior should be kept in mind. Therefore, it is recommended for clinicians to assess a broad range of physical symptoms, in addition to typical neuropsychiatric symptoms, when evaluating patients with ADHD.

Best regards. --BallenaBlanca (talk) 22:28, 14 April 2016 (UTC)

References

Full protection

I've just full-protected this page for 24 hours to prevent edit-warring and allow discussion to take place. I am happy for any admin to unprotect if they feel the problem has resolved. Cas Liber (talk · contribs) 00:33, 25 March 2016 (UTC)

I agree. Thanks, Casliber. It would be good than an administrator take a look at this issue, such as Doc James. Best regards. --BallenaBlanca (talk) 01:29, 25 March 2016 (UTC)

Executive functions

@Doc James: Why did you remove the statements about problems with executive functions in the lead a while back? Seppi333 (Insert 2¢) 10:43, 29 March 2016 (UTC)

To simplify the lead. IMO it is best to describe the symptoms. Than have the discussion of executive functions in the body of the text. Doc James (talk · contribs · email) 10:44, 29 March 2016 (UTC)

Fair enough. Seppi333 (Insert 2¢) 10:47, 29 March 2016 (UTC)

Actually, would you be ok with adding "there are problems with executive functions that cause" before the list of symptoms? It's shorter than what was there previously (the underlined and struckout text is the part you deleted; I'm proposing that we only re-add the underlined text):
Attention deficit hyperactivity disorder (ADHD, similar to hyperkinetic disorder in the ICD-10) is a neurodevelopmental psychiatric disorder in which there are significant problems with executive functions (e.g., attentional control and inhibitory control) that cause attention deficits, hyperactivity, or impulsiveness which is not appropriate for a person's age.

Rephrasing it this way doesn't seem (to me) to be overly technical for the lead. Seppi333 (Insert 2¢) 11:33, 29 March 2016 (UTC)

@Doc James: Your thoughts? Seppi333 (Insert 2¢) 23:09, 29 March 2016 (UTC)

The DSM defines ADHD by the signs and symptoms. The "cause" is unknown. So I do see this proposal as being more complicated.

The ref [5] does not mention "executive function". I am not even clear how that word is defined. Doc James (talk · contribs · email) 09:35, 30 March 2016 (UTC)

The refs for that statement are in this article's section on that topic. An executive function is a particular kind of cognitive process; it's also defined in the section. Seppi333 (Insert 2¢) 11:57, 30 March 2016 (UTC)

IMO it makes the lead more complicated and is not central enough to be mentioned in the lead. Doc James (talk · contribs · email) 13:10, 30 March 2016 (UTC)

Alright. Seppi333 (Insert 2¢) 12:54, 5 April 2016 (UTC)

Does alright mean that you are okay with having "ADHD involves deficits in cognitive control. Stimulants improve cognitive control." in the body of the article which is were it is already? Cognitive control is basically the symptoms of hyperactivity, impulsivity and trouble paying attention. We already state this in the lead and that stimulants help with this in the paragraph on treatment. Doc James (talk · contribs · email) 12:21, 7 April 2016 (UTC)

No, it's my way of acknowledging "I have heard what you said." Arbitrarily adding it back into the lead instead of having a discussion is just me reflecting your behavior at MDMA in this article. FWIW, it also irritates me that instead of having a discussion on the talk page and arriving at some form of compromise version that suits both of us, you decide on an RFC to go with one version or the other when we have content disputes. Seppi333 (Insert 2¢) 12:43, 7 April 2016 (UTC)

A RfC to bring in a larger number of opinions is often useful. Doc James (talk · contribs · email) 13:35, 7 April 2016 (UTC)

When you hold an RFC and frame a question that has only 2 options, you're soliciting a vote, not a discussion. Seppi333 (Insert 2¢) 13:48, 7 April 2016 (UTC)

You were reverting to one of those options until the RfC began. Doc James (talk · contribs · email) 18:47, 7 April 2016 (UTC)

Yes, I was, and so were you, but that's not really relevant. I'm not talking about what we were doing in the article, I'm talking about having a discussion on the talk page in order to arrive at an agreeable compromise. One can discuss what parts of an edit they take issue with and what parts they don't even during a full-blown edit war. Seppi333 (Insert 2¢) 19:00, 7 April 2016 (UTC)

As one who's read a lot on AD/HD, I say leave executive function out of the lead. Seppi333, I agree that it's relevant to the subject — there's abundant literature from researchers exploring the association between EF and AD/HD. However, I'm not convinced that it's essential to describing the disorder. Furthermore, the lead is already overly-detailed, and I agree with Doc James that it needs to be simplified. —Shelley V. Adams ‹blame
credit› 19:35, 8 April 2016 (UTC)

This is a fairly moot issue because I'm not disputing the removal; I don't really care if it's in the lead or not. Nonetheless, ignoring any evidence supporting the characterization, the "AD" in ADHD is nominally an EF disorder. It's not essential to mention this in order to describe ADHD, I agree, but it is for any body of text that gives any serious weight to the pathophysiology of the disorder. The lead of this article is not such a body of text. Seppi333 (Insert 2¢) 20:25, 8 April 2016 (UTC)

References

Not a mental disorder / psychiatric disorder?

We have had in the article for some time that ADHD is both a mental disorder and a neurodevelopmental disorder. Not sure why there are attempts to remove that it is a mental disorder.[6]. All the main listing in the DSM5 are mental disorders / psychiatric disorders. We all agree that it is also a neurodevelopmental disorder.

Doc James (talk · contribs · email) 06:11, 10 April 2016 (UTC)

Right, mental disorder is the umbrella category and then ASD and ADHD both fall under the subcategory called neurodevelopmental disorders. I guess it's might be kind of redundant but I think having both is fine. PermStrump(talk) 07:53, 10 April 2016 (UTC)

Yes mental disorder is a broader term and better understood than neurodevelopmental disorder. Doc James (talk · contribs · email) 08:44, 10 April 2016 (UTC)

Okay so the issue here is that the nebulously-defined term "mental disorder" has somehow stretched to encompass neurodevelopmental disorders. However, calling ADHD a mental disorder is NOT supported by the majority of the scientific literature indexed in pubmed (at least according to a number of somewhat crude queries that I ran in pubmed's search), it is NOT supported by textbooks, books, and (many) journal articles that I've read, it is NOT supported by the DSM-V, it is NOT supported by the CDC, and it is NOT supported by Canadian practice guidelines for ADHD (haven't checked the US ones yet). The loose implication that ADHD may fall under the umbrella of mental disorders does not warrant a specific mention. Note that the autism page explicitly does not list the term mental disorder, even though as you say it is easier to understand (which is true, but it's still wrong).

After going through this page's history, I discovered some differences that were not preserved, so I compromised and used the old format with an updated wikilink (to mental disorders directly). I still don't agree that this is accurate, but at least this way it's clearer about the mental disorder's role without overtly misleading readers. However I would like to point out that including the mental disorder part on the page for at least one of the disorders mentioned on the mental disorder page (primary example: autism) would likely be very poorly received. Garzfoth (talk) 09:47, 10 April 2016 (UTC)

When those places refer to it as a "neurodevelopmental disorder" I don't think they're implying that it's not a mental disorder. In any case, I like the phrase "psychiatric disorder" better than "mental disorder," so personally, I'm fine with the revision in the lead. PermStrump(talk) 16:49, 10 April 2016 (UTC)

Mental disorder and psychiatric disorder mean the same thing. Do not have a strong feeling regarding which one we use.

And use the APA / DSM 5 consider autism to be a psychiatric disorder / mental disorder Doc James (talk · contribs · email) 19:30, 10 April 2016 (UTC)

As far as I can tell the APA/DSM-V does not explicitly state that autism is a mental disorder. With ADHD, I found one or two pages on the APA site that explicitly calls it a mental disorder, neither of which were officially claimed to be the position of the APA (the pages were simplified descriptions intended for the public and apparently weren't maintained by the APA itself either). In short, the only hard evidence that we have is that you can infer all disorders in the DSM are mental disorders based on the title of the book. In pubmed, the term neurodevelopmental disorder (alone) is used most frequently. But I suppose I'm just being pedantic at this point, and I guess calling it a neurodevelopmental psychiatric/mental disorder is fine... However, I'm probably going to insert this term into the autism article(s) for continuity between articles (same rationale applies there), and then see how it's received. Garzfoth (talk) 21:07, 10 April 2016 (UTC)

Personally, I wouldn't do that if the only reason is to be consistent with the ADHD article. I imagine it could be contentious. I do think this wording is more accurate and, more importantly, more clear for people who might not know what a neurodevelopmental disorder is. But I was willing to weigh in on this article, because I'm not aware of an ADHD advocacy group that is specifically dedicated to saying ADHD isn't a disorder. For the autism article, I'm satisfied with it only saying "neurodevelopmental disorder" as long as the first sentence doesn't deny that it's a disorder. PermStrump(talk) 22:15, 10 April 2016 (UTC)

Source for gluten free diet not reliable

In the section on managing ADHD symptoms with diet, a literature review by Ertürk et al. (2016) is used to support this statement: "A 2016 review states that evidence does not support a clear link between celiac disease and ADHD, and that routine screening for celiac disease in people with ADHD and the use of a gluten-free diet are discouraged. However, untreated celiac disease, which often present with mild or even absent gastrointestinal complaints, could predispose to ADHD symptoms, especially those of inattentive type, which may be improved with a gluten-free diet." Now that I've had a chance to thoroughly read the paper, I don't think it's a reliable source for this statement. My issue is with the second sentence, because it was easy to find alternate sources to the support the first sentence alone, like Sethi and Hughes (2015). My issue with Ertürk et al.'s paper is that they contradict themselves in several locations and their conclusions are not supported by actual findings. Only 3 of the 8 studies they found a positive correlation between ADHD and celiacs and only 2 of those studies (both with the same lead author - Niederhofer) "showed" a decrease in ADHD-like symptoms after starting a GFD. All 3 were "low quality" with "very poor internal validity and small sample sizes" according to Sethi and Hughes.

Quotes from sources

Ertürk et al. (2016) For context, in Feb 2016, Ertürk et al. did a lit review of all of the trials ever published on ADHD and celiacs and they found 8 that discussed a possible association between CD and ADHD: Lahat et al. (2000) • Zelnik et al. (2004) • Pynnönen et al. (2004) • Niederhofer and Pittschieler (2006) • Ruggieri et al. (2008) • Niederhofer (2011) • Güngör et al. (2013) • Dazy et al. (2013) After reviewing those 8 studies, these were their findings: p2: Only one study considered ADHD as a possible onset manifestation of CD. However, no improvement was seen after starting a GFD treatment (Diaconu, Burlea, Grigore, Anton, & Trandafir, 2013) 3-4: Only three out of eight studies reported a positive correlation between ADHD and CD: Two studies found an overall higher prevalence of ADHD in patients with CD (Niederhofer & Pittschieler, 2006; Zelnik et al., 2004), and one study reported an over representation of CD in patients with ADHD (Niederhofer, 2011). However, these studies show methodological limitations. The first study of Niederhofer (Niederhofer & Pittschieler, 2006) reported on ADHD symptoms rather than including a formal diagnosis of ADHD. In the other study (Niederhofer, 2011), only CD antibody serology was used to diagnose CD, without a confirmatory biopsy. In both studies, there was no control group (Niederhofer, 2011). The study of Zelnik et al. (2004) screened for combined ADHD and LD in patients with CD, without making a distinction between the presence of ADHD versus learning disorders in CD patients. *Note Ertürk et al. didn't even mention if the 3 studies that showed a positive correlation between ADHD and celiacs found that GFD improved symptoms. In fact, Zelnik et al. explicitly found the opposite. According to other reliable sources, there's so much bias in the Niederhofer studies that they don't count. Yet, somehow Ertürk et al. came to the conclusion that: p4: Newly diagnosed children with CD often complained of “aches and pains,” “easily tired,” “easily distracted,” and “trouble concentrating.” After 1 year of GFD treatment, scores on these items were reduced and remained low in GFD-compliant children (Terrone et al., 2013). Also in newly diagnosed adults with CD, a significant improvement in cognitive functioning, particularly verbal fluency, attention, and motor function, is noted after a 12-month adherence to GFD (Lichtwark et al., 2014). Thus, it is possible that in untreated patients with CD, neurologic symptoms such as chronic fatigue, inattention, pain, and headache could predispose patients to ADHD-like behavior (mainly symptoms of inattentive type), which may be alleviated after GFD treatment. *Note that neither of the 2 studies cited in the conclusion were one of the 8 analyzed for the lit review. And if you look at those two studies, they don't support this statement. Lichtwak et al. (2014) weren't explicitly measuring ADHD or inattention symptoms, Lichtwak and all of the co-authors noted massive conflicts of interest, and their study was heavily criticized for bias and poor design by Lebwohl et al. (2014) for additional reasons. Terrone et al. (2013) also weren't testing for tru ADHD, just "inattention" in combination with other mental health issues like depression, anxiety, oppositional behavior, etc., and they were really vague about what inattention symptoms were reported and didn't show the before and after data. There's a reason they weren't included in Erturk or Sethi and Hughes lit reviews, so it's pretty shady for Erturk to turn around and act like those studies support their hypothesis when the actual studies they analyzed didn't. Sethi and Hughes (2015) also did a lit review of the published studies on celiacs and ADHD. They found 8 studies (with only one difference from Erturk - Chen et al. instead of Pynnönen et al.): Lahat et al. (2000) • Zelnik et al. (2004) • Niederhofer and Pittschieler (2006) • Ruggieri et al. (2008) • Niederhofer (2011) • Güngör et al. (2013) • Dazy et al. (2013) • Chen et al. (2013) This is what Sethi and Hughes found: Overall, based on the currently available low quality evidence, clinicians should not be routinely screening ADHD patients for celiac disease in the absence of additional symptoms (i.e. weight loss, diarrhea, bloating, arthralgias, dermatitis herpetiformis etc.). Additionally, a gluten-free diet should not be a routine recommendation for those patients diagnosed with ADHD, unless there is a concurrent biopsy-proven diagnosis of celiac disease. For several parents, even if serological tests for celiac disease are negative, they may insist on trying their child on an empiric trial of a gluten-free diet. In the absence of objective findings of celiac disease or gluten sensitivity, clinicians should advise against such practices and inform parents of the potential harms of a gluten-free diet. First, a gluten-free diet can be a significant financial burden for a family. Second, starting a child on a gluten-free diet can potentially adversely impact a child’s ability to participate in social activities such as school pizza lunches or birthday parties. And third, a gluten-free diet that is started empirically without first consulting with a dietician carries the risk of long-term nutritional deficiencies. With regards to the primary aim of this study, five out of six observational studies found no association between celiac disease and ADHD. The study by Zelnick et al., was the only study to find a potential association, however, this study had a high risk of reporting bias and detection bias. Both of the controlled trials by Niederhofer found that consumption of a gluten-free diet resulted in a statistically significant decrease in Hypescheme scores. These studies, however, also suffered from very poor internal validity and small sample sizes. Overall, based on the currently available low quality evidence, clinicians should not be routinely screening ADHD patients for celiac disease in the absence of additional symptoms, or unless belonging to a high risk group. In the context of a trial, testing ADHD patients for celiac disease—using an objective blood test— is less vulnerable to detection bias as compared with testing celiac disease patients for ADHD... With regards to whether or not a gluten-free diet can help minimize symptoms of ADHD, there is a need for higher quality evidence that involves both blinding and a placebo controlled arm.

More importantly, beginning a gluten-free diet with out concrete biological markers for celiacs is contraindicated, so there's absolutely no reason we should be suggesting it might help ADHD symptoms. That suggestions should only come from their doctor after definitive diagnosis of celiacs.

• According to the U.S. National Library of Medicine (2014): "You should NOT begin the gluten-free diet before you are diagnosed. Starting the diet will affect testing for the disease."

• Also according to Sethi and Hughes (2015): "For several parents, even if serological tests for celiac disease are negative, they may insist on trying their child on an empiric trial of a gluten-free diet. In the absence of objective findings of celiac disease or gluten sensitivity, clinicians should advise against such practices and inform parents of the potential harms of a gluten-free diet. First, a gluten-free diet can be a significant financial burden for a family. Second, starting a child on a gluten-free diet can potentially adversely impact a child’s ability to participate in social activities such as school pizza lunches or birthday parties. And third, a gluten-free diet that is started empirically without first consulting with a dietician carries the risk of long-term nutritional deficiencies."

I propose this change: "A 2015 review states that evidence does not support a clear link between celiac disease and ADHD, and that routine screening for celiac disease in people with ADHD and the use of a gluten-free diet are discouraged." Another alternative would be not mentioning celiacs at all, which is my #1 preference. PermStrump(talk) 03:54, 15 April 2016 (UTC)

Permstrump said "After reviewing those 8 studies, these were their findings: p2: Only one study considered ADHD as a possible onset manifestation of CD. However, no improvement was seen after starting a GFD treatment (Diaconu, Burlea, Grigore, Anton, & Trandafir, 2013)" This study is not included among the 8 of analysis (the reason is not specified).

Permstrump said: "*Note Ertürk et al. didn't even mention if the 3 studies that showed a positive correlation between ADHD and celiacs found that GFD improved symptoms. In fact, Zelnik et al. explicitly found the opposite. According to other reliable sources, there's so much bias in the Niederhofer studies that they don't count." Sethi and Hughes (2015) is not a reliable source WP:MEDRS. Journal of Family Medicine & Community Health belongs to SciMedCentral publisher and SciMedCentral is included in Beall's List of predators journals]. So we let it out. The 3 studies that showed a positive correlation are:

• Niederhofer & Pittschieler, 2006, (PMID 17085630) CONCLUSION: 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.''
• Zelnik et al.,2004 (PMID 15173490) in effect, states that in their study Therapeutic benefit, with gluten-free diet, was demonstrated only in patients with transient infantile hypotonia and migraine headache. but also "We conclude that the spectrum of neurologic disorders in patients with CD is wider than previously appreciated and includes, in addition to previously known entities such as cerebellar ataxia, epilepsy, or neuromuscular diseases, milder and more common problems such as migraine headache and learning disabilities, including ADHD."
• Niederhofer, 2011 (PMID 21977364) "CONCLUSIONS: Celiac disease is markedly overrepresented among patients presenting with ADHD. A gluten-free diet significantly improved ADHD symptoms in patients with celiac disease in this study. The results further suggest that celiac disease should be included in the ADHD symptom checklist."

• And if we look at the Table 1 of the reliable systematic review, we see that only the two studies of Niederhofer evaluate ADHD prior to diagnosis and analyze results after GFD. Inclusion criteria of Zelnik study is CD on GFD. Really, of 8 studies included on this systematic review, only the two ones of Niederhofer apply the inclusion criteria previous to CD diagnosis. Thus, this conclusion "untreated celiac disease could predispose to ADHD symptoms, which may be improved with a gluten-free diet" are perfectly supported. In addition, they mention two other studies with the same conclusions. However, because of methodological limitations of all analayzed studies, they state "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 GFD as a standard treatment in ADHD.", which is also reflected on ADHD page.

Permstrump said: "More importantly, beginning a gluten-free diet with out concrete biological markers for celiacs is contraindicated, so there's absolutely no reason we should be suggesting it might help ADHD symptoms. " Nobody is recommending to start a gluten-free diet without a diagnosis of CD. "Untreated CD" means both CD diagnosed patients with lack of compliance with the diet and undiagnosed patients, prior to CD diagnosis.

And above all, Wikipedia is not a primary source, not an original research WP:NOR, we have to include conclusions of verifiable secondary sources and this source is a systematic review, published on Journal of Attention Disorders, with a current impact factor of 3.78. The effort of Permstrump reviewing this source is appreciated, but we must not forget that it is a peer-reviewed journal, the criteria for accepting and publishing articles are very strict (most are rejected) and that this review has already been rigorously evaluated by specialists. Therefore, the conclusions are supported and accepted. So I disagree removing the last sentence. We must reflect the conclusions with neutrallity, and not just what we like to say, per WP:NPOV.

Best regards. --BallenaBlanca (talk) 07:36, 15 April 2016 (UTC)

6 out of 8 of the studies Ertürk et al. looked at did not support their hypothesis that GFD improves ADHD-like symptoms. The only 2 studies that supported it were both by the same person (Niederhofer). And we've decided to give equal weight to what Ertürk said about Niederhofer as we are to the other 6 authors. Equal weight is not NPOV (see WP:BALANCE). BallenaBlanca said, "Nobody is recommending to start a gluten-free diet without a diagnosis of CD. "Untreated CD" means by both CD diagnosed patients with lack of compliance with the diet and undiagnosed patients prior to CD diagnosis." That's what the article currently sounds like it's saying. PermStrump(talk) 07:55, 15 April 2016 (UTC)

You are confusing the results. If we analyze ADHD in CD treated patients, and there is no association, it doesn't mean that GFD doesn't improve ADHD symptoms, just the opposite, because the possible preventing role of the diet (In children with CD, however, the risk of developing neuropsychiatric disturbances is only 2.6% (compared with 26% in adults; Ruggieri et al., 2008). This discrepancy may be due to shorter disease duration in children, earlier elimination of gluten from the diet, stricter adherence to a diet, or a different susceptibility to immune-mediated disorders (Lionetti et al., 2010; Ruggieri et al., 2008).) In this review of 8 studies, 3 studies analyze treated CD people (CD on GFD), 3 studies analyze prevalence of celiac antibodies in people with ADHD, and 2 studies analyze people prior to CD diagnosis and after GFD (and found an improvement with a GFD, similar to other two studies not included among these 8 ones). Author's conclusions are the mentioned above and in the ADHD page.

Similar to your reasoning, we could insist on making the conclusion that gluten-free diet may prevent ADHD symptoms in CD people and include it (which moreover is reflected in the paper, so yes we could write it...).

We are Wikipedia editors and this systematic review is written, and already reviewed, by specialists (peer-reviewed). We must reflect the conclusions, that only are equal weight if we mention all of conclusions, and not only a part, because of the different methodologies of the studies analyzed.

Best regards. --BallenaBlanca (talk) 09:03, 15 April 2016 (UTC)

As wikipedia editors, when there's ONE review saying saying ONE other researcher made a certain finding that no one else has made, we can and should conclude that it's WP:UNDUE to include. No, we could not argue that a gluten-free diet may prevent ADHD symptoms because literally none of the studies said that. Moreover, Erturk et al. don't even say in the "clinical implications" section that GFD may improve symptoms, it's only mentioned earlier in the paper. At the end they conclude, "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 GFD as a standard treatment in ADHD. Nevertheless, the possibility of untreated CD predisposing to ADHD-like behavior should be kept in mind. Therefore, it is recommended for clinicians to assess a broad range of physical symptoms, in addition to typical neuropsychiatric symptoms, when evaluating patients with ADHD." This ADHD article is hyperfocusing on 1-2 sentences from Erturk et al.'s paper that do not accurately reflect the entirety of the paper and its overall conclusions. It sounds very much like we're telling people if their stomach is mildly upset and they get distracted easily, they should try eating a gluten free diet, which (a) isn't what any the studies found and (b) is the opposite of the medical recommendation. PermStrump(talk) 12:33, 15 April 2016 (UTC)

References