Talk:Attention deficit hyperactivity disorder

Gluten and ADHD

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: [1] (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 [2], reverted by Garzfoth [3] "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:

Quotation from Ertürk et al.: (Edited to fix layout and create a box)

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

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)

"No, we could not argue that a gluten-free diet may prevent ADHD symptoms because literally none of the studies said that." Non literally, but the authors of systematic review say "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", and ADHD is included among neuropsychiatric disturbances.

"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" Well, now I understand your concerns. Let's specify, to avoid confusion, adding "which may be improved after diagnosis and treatment of celiac disease with a gluten-free diet" [4]. I think now it is quite clear. What do you think?

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

Oh! While I was writing this, Doc James made another edition. [5] I agree with the two options. --BallenaBlanca (talk) 15:14, 15 April 2016 (UTC)

Which two options are you referring to? Doc James (talk · contribs · email) 18:40, 15 April 2016 (UTC)

[6] (mine) and [7] (yours). I prefer the second one (your latest edit): brief and clear. Best regards. --BallenaBlanca (talk) 18:53, 15 April 2016 (UTC)

Doc James, it seems that we can not be so brief, because of concerns of other users Permstrump[8] and Garzfoth [9] To avoid confussions, it seems that is better to expand the text. I will try.

Let me now if you agree. Best regards. --BallenaBlanca (talk) 12:46, 16 April 2016 (UTC)

References

It seems it has been an error

In this edit, Jytdog said “use most recent review”, and he removed the conclusions of 2013 source, but also removed the most recent (of 2014).

I will rescue 2014 conclusions from the text worded by Doc James in this review [10] to adjust and let the most recent review about elimination diets (which they are not synonymous of gluten-free diet, they are a broader term) as Jytdog propose. Nevertheless, it seems that is better not to remove the conclusions of the other review of 2013, to refflect the controversies and give the reader all views and what has been written on the subject.

Let's see what Doc James and other users think.

Best regards. --BallenaBlanca (talk) 12:20, 16 April 2016 (UTC)

This article is not the place to discuss the intricacies of celiac disease. Therefore removed "Its diagnosis requires consider the broad range of physical symptoms of this disease, which can present with mild or absent gastrointestinal complaints and a wide range of non-gastrointestinal symptoms which can affect several organs of the body." This belongs on the celiacs article IMO. (see PMID 26825336) Doc James (talk · contribs · email) 17:47, 16 April 2016 (UTC)

I think the above comment is Doc James based on the edit history, FYI, for the lazy. Elimination diet is not exactly synonymous with gluten and includes a wide range of other foods that more commonly cause GI upset (e.g., milk, eggs). I was coincidentally removing the Nigg et al. (2014) statement at the same time as Jytdog last night and we had an edit conflict. I'm not positive, but I assume we had the same thought process, which was that at the end of the day, Nigg and Sonuga-Barke (2013) essentially said the same thing, which was that any benefits from elimination diets were in studies that selected specifically for kids with ADHD and food sensitivities. I also preferred to cite Sonuga-Barke because Nigg combined all elimination diets in their review, where as Sonuga-Barke looked at the different kinds separately, so citing Sonuga-Barke allows us to be more specific about which types of diets have shown more benefit. The quote chosen for the Nigg citation is taken out of context. In the "Key Points" section at the very front of the article, Nigg et al. say, "A consensus has emerged among most reviewers that an elimination diet produces a small aggregate effect but may have greater benefit among some children. Very few studies enable proper evaluation of the likelihood of response in children with ADHD who are not already preselected based on prior diet response." This is how the article currently presents those 2 sources after BallenaBlanca's recent revert of Jytdog's edits ([157]=Sonuga-Barke et al. 2013; [90]=Nigg et al. 2014):

Tentative evidence supports free fatty acid supplementation and reduced exposure to food coloring.[157] However, these benefits may be limited to children with food sensitivities or those who are simultaneously being treated with ADHD medications.[157] A 2014 review states that an elimination diet could be an effective treatment in a small number of children with ADHD.[90] A 2013 review however did not support an elimination diet.[157]

In the context of what both Sonuga-Barke and Nigg actually said, this is redundant, somewhat incoherent, and a distortion of Nigg et al. (2014). PermStrump(talk) 16:20, 16 April 2016 (UTC)

Permstrump, perhaps you didn't see that this (green) text that you attribute to me is not my wording, but Doc James wording [11]. Compare them and you will notice: This is an old revision of this page, as edited by Doc James (talk | contribs) at 13:46, 16 April 2016 (→‎Diet: adjusted).

Also, I have not reverted Joytdog, I think I have explained it well enough [12]. It was an interpretion error about the meaning of elimination diets and I tried to correct it, respecting the observations of Jytdog, altough I believed that was necessary to add the controversies and also the conclusions of 2013 source, as in fact Doc James did [13].

Please, I ask you be careful with these details, to avoid misinterpretations. I'm trying to reach an agreement among all.

Best regards. --BallenaBlanca (talk) 17:44, 16 April 2016 (UTC)

Corrected some wording. We do not need to lead each sentence with the author. Doc James (talk · contribs · email) 17:47, 16 April 2016 (UTC)

• I've removed "However, untreated celiac disease could predispose to ADHD-like symptoms that may see some improvement with treatment with a gluten-free diet". This is WP:UNDUE - it is a) obvious that treating anyone who has an undiagnosed condition makes them better; b) as the previous sentence just said, there is no call to screen everyone with ADHD for coeliac but this sentence implies that we should do. Reading the content as it stood this stood out like a sore thumb. Jytdog (talk) 20:11, 16 April 2016 (UTC)

The way Doc James fixed it makes it's clear which information came from which study without needing their names. I didn't particularly care about having their names in there; I was just trying to clarify the original wording and that was the best I came up with. The current version is my favorite so far. PermStrump(talk) 20:43, 16 April 2016 (UTC)

Jytdog, you said that you have removed "However, untreated celiac disease could predispose to ADHD-like symptoms that may see some improvement with treatment with a gluten-free diet" because of:

“b) as the previous sentence just said, there is no call to screen everyone with ADHD for coeliac but this sentence implies that we should do.” Includin the sentence that you have deleted is not WP:UNDUE, on the contrary saying “A 2016 review did not support a clear link between celiac disease and ADHD, and stated that routine screening for celiac disease in people with ADHD and the use of a gluten-free diet as standard ADHD treatment are discouraged.[158]” and hiding “untreated celiac disease could predispose to ADHD-like symptoms that may see some improvement with treatment with a gluten-free diet"” may be cherry picking or quote mining: you are ignoring the rest of the article, ignoring “those that moderate the original quote” (and you have also deleted previous conversations of this talk page, in which I showed the context of conclusions). I write again:

Ertürk et al. say:

“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.” "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)." “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” “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 … Thus, it is posible 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.”

a) obvious that treating anyone who has an undiagnosed condition makes them better; This is an ambiguous, simplistic and non specific reasoning. We are talking about ADHD, you must focus on ADHD. If we give treatment and cure sore throat, sinusitis, flu... in a person with ADHD, he/she will obviously feel better, but that will not take away the symptoms of ADHD. ADHD symptoms will only improve if we treat a medical condition which may cause in some people ADHD symptoms, as hyperthyroidism, sleep apnea, drug interactions, etc. And as we see above, Ertürk et al. after review the literature state that several studies show that ADHD symptoms in some people with ADHD and CD improve with a gluten-free diet (which is not the same as “makes them better”) and list the current hypothesis for this causative effect.

Also, if you are so kind, I'd like you to explain me what is the criteria that you apply to "remove excess quotation" (one quotation that talks about eliminations diets, and other one with the conclusions of the systematic review about ADHD on CD people, and the effect of gluten-free diet in undiagnosed CD people with ADHD, extracted because this is a non free-access paper) and " remove quotation clutter from ref. makes editing way harder than it needs to be)" (removing again the quotation talking about the conclusions of the systematic review about ADHD on CD people, and the effect of gluten-free diet in undiagnosed CD people with ADHD), and you consider, however, that these others 13 quotations can remain:

• 17. (231 characters, talking about epidemiology and underdiagnosis)
• 23. (655 characters, talking about pharmacological interventions)
• 90. (258 characters, talking about elimination diets)
• 97. (1,505 characters, talking about psychostimulants)
• 98. (919 characters, talking about treatment with 5HT)
• 110. (617 characters, talking about pharmacotherapy and interventions to improve motivational processes)
• 134. (750 characters, talking about exercise interventions)
• 135. (1,224 characters, talking about exercise interventions)
• 145. (379 characters, saying that changes and alterations in limbic regions are more pronounced in non-treated populations)
• 146. (726 characters, talking about amphetamine psychosis and findings from one trial which indicate that the use of antipsychotic medications effectively resolves symptoms of acute amphetamine psychosis)
• 147. (522 characters, talking about side effects of stimulants)
• 151. (574 characters, talking about treatment with stimulants, amphetamines and methylphenidate, and school failure in untreated children)
• 157. (244 characters, talking about free fatty acid supplementation and artificial food color exclusions)

Best regards. --BallenaBlanca (talk) 06:32, 17 April 2016 (UTC)

It is not a question of character count. It is that a) there is no current recommendation to test all people with ADHD for coeliac; b) the obvious fact that a person with any untreated disease improves if you treat it. And the only reason we are having this discussion is because you won't listen to every other person in this discussion. You are not collaborating you are driving your POV down on throats. Stop it already. Jytdog (talk) 06:48, 17 April 2016 (UTC)

No problem, Jytdog. I will stop edit on ADHD page for the moment, I will continue listenning other users and I will continue collaborating.

Perhaps, the reason why you think I am no listening and collaborating is that you have not noticed that you have archived previous conversations (16 april), conversations that are not closed WP:TALK Wikipedia:Talk page guidelines#Closing discussions, this is the continuation. Perhaps I may have been wrong with the hierarchy of this section when I created it and wrote ==, instead of ===

If you delete my contributions, in which I was clearly listening, collaborating and trying to reach a consensus, and in which other users as Doc James agreed with the inclusion of the reference to gluten-free diet (not my point of view), other users who read it now will be making a wrong idea. The information again remains hidden. I disagree with archive them, you didn't ask us if you can archive them. WP:TALK

Thus, I will rescue the active conversation ("If content is archived prematurely, such as when the discussion is still relevant to current work or discussion of a subject was not concluded, restore the content to the talk page from the archive."WP:ARCHIVENOTDELETE) and fix layout/hierarchy errors.

Best regards. --BallenaBlanca (talk) 10:39, 17 April 2016 (UTC)

What I archived were WP:TEXTWALL from you - unreadable walls of text that were yet more examples of you overwhelming the conversation in your efforts to push and push and push. They are not examples of collaboration. Really - no one agrees with what you want here. Jytdog (talk) 10:46, 17 April 2016 (UTC)

Resolved, I agree. [14] --BallenaBlanca (talk) 18:17, 18 April 2016 (UTC)

DSM4

Just because we have the DSM5 does not mean every bit of research based on the DSM4 is all of a sudden obsolete. Doc James (talk · contribs · email) 17:51, 17 April 2016 (UTC)

Reviews

Some of these sources were reviews. This edit also changed 75% from genetics to 5%?[15] Doc James (talk · contribs · email) 18:03, 17 April 2016 (UTC)

nice catch on that 15x change! yikes. Jytdog (talk) 08:47, 18 April 2016 (UTC)

Oops! Sorry about that. I just meant to delete the random characters before the 7 and didn't notice that I nicked the 7. I'll write more about why I removed some of the other stuff. Some of the things I had more of a reason than what I wrote in the edit summary (like the DSM IV thing, but I don't remember off the top of my head). I have to go back and look to see what they were. PermStrump(talk) 15:08, 18 April 2016 (UTC)

Starting with 1 paragraph about evolutionary psychology behind ADHD, here's a link to the changes and I'm looking at the 1st chunk added back in under line 94:

• As ADHD is common, natural selection likely favored the traits, at least individually, and they may have provided a survival advantage. For example, some women may be more attracted to males who are risk takers, increasing the frequency of genes that predispose to ADHD in the gene pool. As it is more common in children of anxious or stressed mothers, some argue that ADHD is an adaptation that helps children face a stressful or dangerous environment with, for example, increased impulsivity and exploratory behavior.

The first 2 sources disappear from the search results in my employer’s database (a university library) when I filter for peer reviewed articles. The description of both journals says that they are peer reviewed, but I guess not 100% of the content is peer reviewed. For example, the description for Revista Neurologica says, “Key Features” are peer reviewed and that “Other Features” include: book reviews and “Reviews included (any)”, so presumably the “other features” aren’t peer reviewed. The paper appeared in a supplement issue of that journal, so my guess is that the supplement wasn’t peer reviewed. It has happened before where some articles in the same journal were labeled peer reviewed but others weren't, so somehow the database seems to know that. I can’t read the Spanish one, but I couldn’t verify the content from the 2nd source regardless of its peer review status. As for the 3rd source, this isn’t an accurate interpretation of what the author was trying to convey. It reflects one sentence out of 5 paragraphs on the potential evolutionary theories behind ADHD and this point wasn’t the takeaway message that I got from it. The author was basically describing other authors’ untested speculations without validating one over another or coming to any final conclusions, so I felt choosing any of the 5 theories was kind of cherry picking b/c they were all different and untested anyway. More to come... PermStrump(talk) 17:22, 18 April 2016 (UTC)

References