J. Pediatr. (Rio J.) vol.93 número3

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www.jped.com.br

ORIGINAL

ARTICLE

Psychopathology,

quality

of

life,

and

factors

in

children

with

celiac

disease

夽

Eylem

Sevinc

¸

a,∗

,

Fatih

Hilmi

C

¸etin

b

,

Banu

Demet

Cos

¸kun

c

a_Emel_Mehmet_Tarman_Children’s_Hospital,_Department_of_Pediatric_{Gastroenterology,}_Kayseri,_Turkey

b_Emel_Mehmet_Tarman_Children’s_Hospital,_Department_of_Child_and_Adolescent_Psychiatry,_Kayseri,_Turkey c_Kayseri_Training_and_Research_Hospital,_Department_of_{Gastroenterology,}_Kayseri,_Turkey

Received28April2016;accepted28June2016 Availableonline23November2016

KEYWORDS Celiacdisease; Qualityoflife; Child;

Psychiatricdiagnosis

Abstract

Objective: Thisstudyaimedtosurveychildrenwithceliacdisease(CD)forpsychiatricdisorders,

determinethepossiblefactorsthatpredictpsychopathology,andanalyzehealth-relatedquality oflifeandpossiblefactorsthatcouldaffectthequalityoflife.

Methods: In this study, all children completed the Schedule for Affective Disorders and

Schizophrenia for SchoolAge Children---Present and LifetimeVersion ---TurkishVersion (K-SADS-PL-T),aswellasthePediatricQualityofLifeInventory(PedsQL)forthe8---12agegroup, andasentencecompletiontest.Aface-to-faceinterviewwasperformedwiththeparentsof theparticipantstoinformthemaboutthestudy.

Results: Thisstudyincluded52childrenwithceliacdiseaseintheagerangeof8---12years,and

40healthychildren.Themeanageofthestudygroupwas10.36±0.36years,and31(59%)of themwerefemales.Themeanageofthecontrolgroupwas10.35±0.46yearsand24(60%)of themwerefemales.ThemeansubscalescoresofthePediatricQualityofLifeInventorywere significantlylowerinchildrenwithceliacdiseasewhencomparedtothecontrolgroup(p<0.05). Therewasatleastonepsychiatricdisorderinthe26(50%)childrenwithceliacdisease.

Conclusions: Thisstudyhasshownoncemorethatceliacdiseaseisassociatedwithsome

psy-chiatricsigns/diagnoses,andthatitdecreasedqualityoflife.Furtherstudiesareneededto determinethefactorsthatcouldreducethepsychiatricsigns.Itisapparentthatthosestudies wouldcontributenewapproachestoimprovediagnosis,treatment,andqualityoflife. ©2016SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/ 4.0/).

夽

Pleasecitethisarticleas:Sevinc¸E,C¸etinFH,Cos¸kunBD.Psychopathology,qualityoflife,andrelatedfactorsinchildrenwithceliac disease.JPediatr(RioJ).2017;93:267---73.

∗_{Corresponding}_author.

E-mail:dr.eylemsevinc@gmail.com(E.Sevinc¸).

http://dx.doi.org/10.1016/j.jped.2016.06.012

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PALAVRAS-CHAVE Doenc¸acelíaca; Qualidadedevida; Crianc¸a;

Diagnóstico psiquiátrico

Psicopatologia,qualidadedevidaefatoresrelacionadosemcrianc¸ascomdoenc¸a celíaca

Resumo

Objetivo: Neste estudo,foramavaliadas crianc¸as comdoenc¸acelíaca (DC) para verificara

existênciadetranstornos psiquiátricos,determinarospossíveisfatores quepredizem psico-patologiaeanalisar aqualidadedevidarelacionada àsaúdeepossíveisfatores quepodem afetá-la.

Métodos: Nesteestudo,todasascrianc¸asresponderamàEntrevistaparaTranstornosAfetivos

eEsquizofreniaemCrianc¸asemIdadeEscolar---VersãoPresenteeaoLongodaVida---Versão Turca(K-SADS-PL-T),bemcomoaoInventárioPediátricodeQualidadedeVida(PedsQL)dafaixa etáriade8-12anoseaotestedecompletarsentenc¸as.Umaentrevistapresencialfoirealizada comospaisdosparticipantesparainformá-lossobreoestudo.

Resultados: Esteestudoincluiu52crianc¸ascomDCentreasidadesde8a12anose40crianc¸as

saudáveis.Aidademédiadogrupodeestudoerade10,36±0,36anos,e31deles(59%)eramdo sexofeminino.Aidademédiadogrupodecontroleerade10,35±0,46anos,e24deles(60%) eramdosexofeminino.OsescoresmédiosdassubescalasdoPedsQLforamsignificativamente menoresem crianc¸ascomDCquandocomparadoscomogrupodecontrole(p<0,05).Havia pelomenosumtranstornopsiquiátricoem26(50%)crianc¸ascomDC.

Conclusões: Este estudo mostrou mais uma vez que a DC está associada a alguns

sin-tomas/diagnósticos psiquiátricos e reduziu a qualidade de vida. São necessários estudos adicionaisparadeterminarosfatoresquepodemreduzirossintomaspsiquiátricos.Estáclaro queessesestudoscontribuiriamcomnovasabordagensparamelhorarodiagnóstico,o trata-mentoeaqualidadedevida.

Introduction

Celiac disease (CD) is a chronic, inflammatory, immune-mediated disease characterized by persistent intolerance ofthesmallintestinestogliadin.1_Its_prevalence_is

approxi-mately1%inmostcountriesoftheworld.Themanifestations of CD can be divided into gastrointestinal symptoms and extraintestinalsymptoms.Thediagnosisdependson gluten-dependent symptoms, CD-specific antibody levels, the presence of human leukocyte antigen (HLA-DQ2) and/or HLA-DQ8,andcharacteristichistologicalchangesinthe duo-denalbiopsy. In thepresence of highantibody levels,the diagnosisofCDmaybebasedonacombinationofsymptoms, antibodies, and HLA, thus omitting the duodenal biopsy. Compliancewitha gluten-freediet(GFD) is monitoredby endomysiumantibody(EMA)status.2_The_treatment_consists

ofremovingglutenfromthedietthroughoutlife.3_Just_like

other chronic diseases, CD affects physical, mental, and sociallife, aswell asthe health-relatedquality oflife of children.4

Anumberofstudieshave investigatedtheeffectofCD onqualityoflifeandpsychopathology.Althoughthe preva-lenceofmajordepressivedisorder,dysthymicdisorders,and adjustmentdisordersvariesbetween10and80%,theyare themost commonpsychiatricdisorders(PD)inadultsand childrenwithCD.5_The_basic_factor_focused_on_in_those

stud-ieswasthequalityanddegreeofadherencetotheGFD.Itis knownthatlifelongGFDincreasesperceptionofwell-being andpositivefeelingsinsomedomains,anddecreasesthose perceptionsinsomeotherdomains.6_In_conclusion,_children

withCD trying toadapt GFD are at risk for psychological disorders.

Mostofthestudiesintheliteraturethatinvestigated psy-chopathologyandqualityoflifewereconductedonadults, and the data on children are scarce.7 _The _present _study

aimedtoscreenchildrenwithCDforPD,determinepossible factors that predict psychopathology,and analyze health-relatedqualityoflifeandthepossiblefactorsthataffected thequalityoflifeinthosechildren.

Methods

Samples

This cross-sectional study was carried out with fifty-two patients who were formerly diagnosed with CD recruited fromtheDepartmentofPediatricGastroenterology, Emel-Mehmet Tarman Children Hospital in Kayseri, Turkey, betweenJanuaryandMarch2016.ThediagnosisofCDwas based on the criteria outlined by the European Society forPediatricGastroenterology,Hepatology,andNutrition.8

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those on GFD for less than six months. The study sam-plewaschosenamongchildren betweentheagesof8---12 years, which represented the period that children begin schoolandleavetheOedipalstage.Thus,theyexperience and try to handle social and academic stresses. In order todetermine theeffectof compliancetoGFD, theceliac groupwassubdividedintoadietarycompliantgroupanda dietarynoncompliantgroupaccordingtoserumEMAlevels. Forty age- andsex-matched healthychildren whodid not haveanygastrointestinaldisorderorPDandadmittedtothe Emel-MehmetTarmanChildrenHospitalforvariousreasons were included as controls. All of controls had a negative serumEMAtest. Allcharacteristics includingage, gender, symptoms, weight,height, body mass index(BMI), serum EMAlevel,andfamilycharacteristics(numberofhousehold members, socioeconomic status, PD in the history) were evaluated.

Inthesecondstepofthestudy,allpatientsincludedin thestudywereexaminedbythechildpsychiatrist.All parti-cipantsweregiventheScheduleforAffectiveDisordersand SchizophreniaforSchoolAgeChildren---PresentandLifetime Version--- Turkish Version(K-SADS-PL-T),asemi-structured diagnostictool.TheywerealsogiventhePediatricQuality ofLifeInventory(PedsQL)8---12 agegroupanda sentence completiontest,andtheparentswereinterviewedtoobtain informationabout their children. In addition,the authors completedthesociodemographicdataform.Thestudywas approved by the Ethics Committee for Non-invasive Clin-ical Research of Kayseri Training and Education Hospital, underNo.2016/49. Allparticipants providedtheirwritten informedconsent,andparticipatedinthestudyvoluntarily.

Datacollectiontools

K-SADS-PL

This is a semi-structured scale developed by Kauffman etal.toscreenpsychopathologyinchildrenandadolescents between the ages of 6 and 18 years.9 _In _this _scale,

psy-chopathologyisinvestigatedbycombiningthedataobtained from the parents and the child. The psychopathologies includedinthescaleincludemood,psychosis,anxiety, dis-ruptivebehaviordisorder,eliminationdisorders,eatingand ticdisorders,andalcohol andsubstanceabuse.Reliability andvalidityoftheK-SADS-PLinTurkishwasverifiedby Gök-leretal.10

PedsQL

This is a general quality of life tool used in 2---18 year-oldchildrenandadolescents.11_Emotional_functioning_score

(EFS), social functioning score (SoFS), school functioning score(ScFS),totalphysicalhealthscore(TPhHS),total psy-chosocialhealthscore(TPsHS),andtotalscalescore(TSS) areusedinthescale.A5-point,Likert-typescoringscaleis usedinthescale(0=never,1=almostnever,2=sometimes, 3=often,4=almostalways).The scoresobtainedfromthe itemsarelinearlytransformedintoavaluebetween0and 100(0=100,1=75,2=50,3=25,4=0).Thequalityoflife increasesasthescoresincreasesfrom0to100.12_The

relia-bilityandvalidityofthePedsQLforages8---12andforages 13---18inTurkishwasstudiedbyCakinMemiketal.,and8---12 year-oldformwasusedinthisstudy.13

Beiersentencecompletiontest

Being one of the projection techniques, this test has a wideusagearea.Ithas twoforms; FormA,which is suit-able for children, can be applied to ages 8---16. Via this testtheindividualsprojecttheirinterests,feelings, behav-iors,wishes, sadness,andthe otherimportantpersonality featuresagainstanunclearstimulant.Thus,consciousand unconsciousemotionsandideascanbeobtainedfromthe individual.Withthistest,problemsseenfrequentlyin envi-ronmentslikeschoolandthehomecanbedetected.

Sociodemographicdataform

Via this data form, prepared by the authors, the name (optional), age, sex, and the number and the identity of householdmembers wereidentified byasking the partici-pantortheirfamily.Inthisform,thesocioeconomiclevel wasdeterminedinaccordancetoincomeofthefamily.An incomethree-fold or more of minimumwage was consid-ered as a good, an income between minimum wage and three-foldofminimumwagewasconsideredasamoderate, andan incomeat thelevel of minimumwage or less was considered as low socioeconomic level. Their history was assessedregardinganyprevious diagnosisof PD,the pres-enceofPDinfamily,andanyinformationrelatedCDsuch asdateofdiagnosis,bodyweight,height,primary gastroin-testinalsymptoms,andthecompliancewiththeGFD.

Statisticalanalysis

Thedata wereanalyzed withSPSSversion 16.0(SPSSInc. Released 2007. SPSS for Windows, version 16.0. IL, USA). Descriptive statistics were presented as mean, standard deviation, and percent. Student’s t-test for independent sampleswasusedtodeterminethesignificanceofthe inter-group differences for quantitative variables with normal distributions.Qualitativevariableswerecomparedwiththe chi-squaredandFisher’sexacttests.The normalityofthe distribution of data was analyzed with the Shapiro---Wilk test.ItwasdeterminedthatthesubscalescoresofPedsQL werenotdistributednormally,andSpearman’scorrelation analysis, Mann---Whitney, chi-squared, and Kruskal---Wallis tests were used to compared the data without normal distributions. A p-value of less than 0.05 was considered significant.

Results

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Table1 Sociodemographic-cliniccharacteristicsofthestudyandthecontrolgroups.

Studygroup(n=52) Controlgroup(n=40) p

Age(years)(mean±SD,a_min---max) _10.36_±_0.36_(8---12) _10.35_±_0.46_(8---12) _0.700

Gender(Female/male,%) 31/21(59%/41%) 24/16(60%/40%) 0.650

Householdmembers(mean±SD) 4.66±1.22 4.46±0.97 0.088

Height(cm;mean±SD) 129.50±8.67 134.42±7.89 0.176

Weight(kg;mean±SD) 27.05±8.85 33.57±8.22 0.491

BMI(kg/m2_;_mean_±_SD) _16.02_±_1.07 _16.95_±_1.14 _0.627

Ageatfirstdiagnosis(years;mean±SD) 6.4±2.2

Durationoffollowup(years;mean±SD) 3.94±1.10

Adherencetogluten-freediet(n,%)b

Goodadherence 16(30%)

---Pooradherence 36(70%)

Socioeconomiclevel(n,%)

Low 10(19%) 8(20%) 0.79

Moderate 37(82%) 28(70%)

High 5(9%) 4(10%)

Parenteducation(maternal---paternal,n,%)

Elementaryschool 8(16%)---7(13%) 6(15%)---6(15%) 0.842c

Middleschool 35(67%)---28(53%) 25(62%)---24(60%) 0.322d

Highschool 9(17%)---17(34%) 9(23%)---10(25%)

a_Standard_deviation.

b _Good_adherence_to_diet:_the_patients_with_a_serum_endomysium_antibody_(EMA)_level_<20_RU/mL.

c _There_were_no_significant_differences_between_the_celiac_group_and_controls_for_maternal_education_status. d _There_were_no_significant_differences_between_the_celiac_group_and_controls_for_paternal_education_status.

witha GFD(non-strictdietor somegluten),whostill suf-feredchronic gastrointestinalsymptoms.The meanserum EMAlevelwas140RU/mL(0---760)inchildrenwithCD,and 16(30%)ofthemadheredtoGFDwell;ontheotherhand,all ofthecontrolshadanegativeserumEMAtest.PDwere iden-tifiedinsix(11%)familiesinceliacgroupandinthree(7%) familiesinthecontrolgroup,andtherewasnosignificant differencebetweentheceliacandcontrolgroups(p>0.05). The meannumber of household members(4.66±1.22 vs. 4.46±0.97,p>0.05)wasnotsignificantlydifferentbetween celiacgroupandcontrols. Asfor parents,fatherswerean averageof36.6yearsandthemothersof32.3years,andit wasalsoobserved that35(67%) ofthechildren’smothers and28(53%)oftheirfathershadgraduatedmiddleschoolin theceliacgroup.Table1showsthattherewereno signifi-cantdifferencesbetweenceliacgroupandcontrolsforage, gender,height,BMI,andfamilycharacteristics(p>0.05).

When the meansubscalescores of PEDSQL weretaken intoconsiderationinchildrenwithCD,itwasobservedthat TPhHSwas79.68,EFSwas82.50,SoFSwas97.50,ScFSwas 90,TPsHS was90, andTSS was87.50,while thosescores were100,90,90,100,90,and92.30inthecontrolgroup, respectively.ThePedsQLsubscalescores(Table2)were sig-nificantlylowerinchildrenwithCD(p<0.05).

The effects of sociodemographic variables on subscale scoresofPedsQLwereanalyzed.MeanTPhHSandEFSscores weresignificantlyloweringirls withCDcomparedtoboys withCD;however,therewerenodifferencesformeanSoFS, ScFS, TPsHS, or TSS scores. The children with CD were dividedintothreegroups accordingtotheirincomelevels (low---medium---high),andtheydidnotshowany signifi-cantdifferencesfor PedsQLsubscalescores(p>0.05).The

Table2 MeanPediatricQualityofLifeInventory(PedsQL) subscalescoresforthestudyandcontrolgroups.

Studygroup (n=52)

Controlgroup (n=40)

p

EFS 82.5(0---100)a ₉₀_(0---100)a _0.003

SoFS 97.5(50---100)a ₉₀_(70---100)a _0.024

ScFS 90(45---100)a ₁₀₀_(80---100)a _0.000

TPhHS 79.68(34.37---100)a ₁₀₀_(75---100)a _0.005

TPsHS 90(41.65---100)a ₉₀_{(76.66---100)}a _0.039

TSS 87.50(44.56---100)a _92.30_{(84.78---100)}a _0.000

EFS,emotionalfunctioningscore;SoFS,socialfunctioningscore; ScFS, school functioning score; TPhHS, total physical health score;TPsHS,totalpsychosocialhealthscore;TSS,totalscale score.

a _Median_(min---max).

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Table3 Effectsofsociodemographic-clinicalvariablesonthePediatricQualityofLifeInventory(PedsQL)subscalescoresin childrendiagnosedwithceliacdisease.

EFS SoFS ScFS TPhHS TPsHS TSS

Psychiatricdiagnosis

Present 85 100 90 75 90.8 85.4

Absent 75 95 87.50 84.30 86.81 84.7

p 0.519 0.206 0.514 0.755 0.433 0.219

Gender

Male 85 100 95 87.5 90 90.12

Female 75 95 90 75 88.3 83.69

p 0.040a _0.897 _0.488 _0.032a _0.167 _0.107

Adherencetogluten-freedietb

Goodadherence 72.5 95 87.5 70.3 85 80.43 Pooradherence 85 100 90 84.3 90.8 85.80

p 0.414 0.464 0.425 0.052 0.433 0.219

Socioeconomiclevel

Low 87.5 100 92.5 78.12 92.49 84.85

Moderate 80 95 90 83.5 90 84.7

High 70 100 90 84.37 85 83.69

p 0.650 0.137 0.951 0.703 0.763 0.979

Durationofdiseasec

r −0.249 0.036 −0.300 −0.362 −0.240 −0.313

p 0.755 0.798 0.031a _0.008a _0.875 _0.025a

EFS,emotionalfunctioningscore;SoFS,socialfunctioningscore;ScFS,schoolfunctioningscore;TPhHS,totalphysicalhealthscore; TPsHS,totalpsychosocialhealthscore;TSS,totalscalescore.

a _p_<_0.05.

b _Good_adherence_to_diet:_patients_with_a_serum_endomysium_antibody_(EMA)_level_<20_RU/mL. c _Spearman’s_correlation_analysis.

TherewerenoPDin26(50%)ofthechildrenwithCD.On theotherhand,ten(19%)haddepression,sixhad(12%) anxi-etydisorder,fivehad(9%)adjustmentdisorder,two(4%)had concomitantdepressionandanxietydisorder,andthree(6%) hadconcomitantadjustmentdisorderandanxietydisorder. The effects ofsociodemographic variablesonpresence of psychopathologywereanalyzed inTable 4.There were no significant differences for sociodemographic variables between patients with a psychiatric diagnosis and those withoutapsychiatricdiagnosis(p>0.05).

Discussion

Inthis study,theauthorsinvestigatedqualityof life, psy-chopathology,andtheprobablefactorsassociatedwithboth concepts,andfoundthatallsubscalescoresofPedsQLwe significantlylowerinthestudygroup.Inthisregard,itwas concluded that CD impaired quality of life by decreasing functionalityin social relations,emotional life,and phys-icalhealth. Itwasalsofound thatatleastonepsychiatric diagnosiswaspresentinhalfofthecases.

Interestingresultswerereportedintheliterature regard-ingqualityoflifeandpsychopathologyinchildrenwithCD. Petersetal. reportedthatexposure toglutenresulted in depressivesymptomseventhoughit didnotresultin gas-trointestinal symptoms in patients with non-celiac gluten sensitivity,whichmightexplainwhythepatientswith non-celiacgluten sensitivity feltbetter witha GFD.14 _A_study

followedupnineadolescentswithCDbetweentheagesof 12 and 16 years for six months on a monthly basis with theK-SADS-PLand achild behaviorcontrol list,and mea-suredserumaminoacidandantibodylevelsbeforeandafter GFD.The authorsdiagnosedthreeadolescentswithmajor depressivedisorder,twoadolescentswithdisruptive behav-iordisorder,andoneadolescentwithalearningdifficulty; however,theydidnotfindanyPDinfour(44%)patients.In thesamestudy,itwasreportedthatthetryptophanlevelsof theadolescentswerelowbeforeGFD,andpsychiatric symp-tomsdecreasedandserumtryptophanlevelsincreasedthree monthsafterstartingthediet.15_Those_results_by_Pynnönen

etal.indicatethatthemostimportantfactorforthehigh psychiatricdiagnosisprevalenceinthepresentstudywasthe lowadherenceratetoGFD.Wagneretal.performedastudy toinvestigatetheeffectsofadherencetoGFDonqualityof life on283 adolescentswith CD and 82 healthy controls. Theauthors didnotfindanydifferencebetweenthe ado-lescentsthatadheredtothedietandthehealthycontrols forqualityoflifeandwell-being;however,theadolescents whodidnotadherediethadworsequalityoflife;theyfelt sick,hadmore psychiatricproblems, and hadmore prob-lemsinschool.Inthesamestudy,itwasemphasizedthat adherencetothedietwasthemain factor foran optimal qualityof life, andthose withlow adherence tothe diet shouldhave psychologicalsupport.16 _Those_data _show_the

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Table4 Effectsofsociodemographic-clinicalvariableson thepresenceofpsychopathologyinchildrendiagnosedwith celiacdisease.

Presenceofa psychiatric diagnosis (n=26)

Absenceofa psychiatric diagnosis (n=26)

p

Gender(n)

Male 11 10

0.780

Female 15 16

Adherencetogluten-freediet(n)a

Goodadherence 7 9

0.535 Pooradherence 19 17

Socioeconomiclevel(n)

Low 7 3

0.290 Moderate 16 21

High 3 2

Durationofdiseaseb

1---3years 14 16

0.800 4---7years 12 10

a_Good_adherence_to_diet:_patients_with_a_serum_endomysium

antibody(EMA)level<20RU/mL.

b _Spearman’s_correlation_analysis.

withGFDandthehighprevalenceofpsychiatricdiagnoses arenotableinthepresentstudy,thedegreeofthe compli-ancewithGFDwasnotdirectlycorrelatedwiththepresence or absenceof apsychiatricdiagnosis. Even when possible variants(sex,durationofdisease)wereexamined,adirect correlationcouldnotbeshown.Therefore,toevaluatethe potentialeffectoflowGFDcomplianceontheappearance ofpsychopathology,alargerstudysamplemaybeneeded.

The most frequently diagnosed disease wasdepression (23%) in this study; however, the rates of anxiety (22%) and adjustment (15%) disorders were also high when the comorbid diagnoses were taken into consideration. From anotherpointof view, lowrate ofadherence toGFDmay meanmoreexposuretogluten,andhencemorepsychiatric signs/diagnoses.Although the etiopathogenesis of psychi-atricsigns/diagnosesobservedinCDisnotclear,tryptophan deficiencyduetomalabsorptioninpatientswithpoor adher-ence to diet may cause a hyposerotonergic state in the centralnervoussystem.17---20_Another_important_factor_is

psy-chosocialstressrelatedtoCDandGFD.21---23 _Not_being_able

todineout,difficultytofindgluten-freefoods,and incon-venience in school and social life result in isolation and stigmatization.Thosemaycauselowself-esteem,and con-stituterisk factorsfor psychopathology.24,25 _In _accordance

withtheliteratureandinconjunctionwiththehigh preva-lence of psychopathology seen in the present study, the statementsthatindicatedlowself-esteeminsentence com-pletion test were as follows: ‘‘unfortunately I am a sick person,’’‘‘IwishIwasnotsick,’’‘‘Idon’tunderstandwhy Iamsick,’’and‘‘IneverforgetthatIamsick.’’

An interesting point in this study is that emotional functionality and physical health were affected more in girls. Supporting those data, all patients diagnosed with depression were girls in the study that investigated nine

adolescentswithCD.15_Various_studies_have_reported_higher

anxiety levelsin women diagnosedwithCD26---28 _and _some

others indicated that emotional well-being significantly improvedwithGFDinwomen.22_Studies_conducted_on_adults

showed that duration of disease was another factor that couldaffectthequalityoflife.Barrattetal.didnotshow a correlation between duration of disease and quality of life.29 _On _the_other _hand,_Roos_et_al._did_not_find_any

dif-ferencebetweenpatientswithCDwhohadbeentreatedfor tenyearsandthecontrolgroup.30_{Contradictory}_results_may

beexplainedbythedifferencesinadherencetoGFD. Itis clearthatpatientswithlowadherencetoGFDwillbecome worse,bothregardingphysicalandpsychologicalwell-being. Inthepresentstudy,therateofadherencetodietwaslow, andphysicalhealth,schoollife,andemotionalfunctionality scoresdecreasedasthedurationofthediseaseincreased.

This study has some limitations. First, it was cross-sectional, and there was no prospective follow-up. Therefore, there are no data concerning how the ther-apeutic interventions of the child psychiatrist affected adherence todiet, quality of life, and frequency of psy-chopathology.Inaddition,thesmallnumberofthepatients includedpreventsgeneralizationoftheresults.Norelation wasfoundbetweenhighdiagnosisprevalenceandthe inves-tigatedvariants,andthismaybeduetothesmallsizeofthe studysample.

Inconclusion,thisstudyshowedimpairedqualityoflife andincreasedrateofpsychopathologyinchildrenwithCD. When the possible factors that cause these results were investigated,itwasfoundthattheseoutcomesarerelated withbeingfemaleandthedecreaseinsomepartsofquality oflifeduetothedurationofthedisease.Ontheotherhand, accordingtothesefindings,bothimpairedqualityoflifeand increased psychopathologies werenot related with worse compliancewitha GFD. Fromthispoint, further prospec-tivestudieswithlargersamplesizeareneededtodetermine the factors that affect quality of life and high frequency ofpsychopathologyinpatientswithCD.Thepresent study indicatesthatchildren andadolescentsdiagnosedwithCD shouldbefollowedupbyachildpsychiatristforasuccessful adherencetodiet,andhenceanoptimalqualityoflifeand mentalhealth.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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