Celiac disease is associated with behavioral and emotional disorders in children, but in most studies the psychopathology is detected in the setting of already knowing a child has celiac disease. What about before the diagnosis of celiac disease is made? Do children with behavioral issues have a higher likelihood of developing celiac disease compared to children who do not have this gastrointestinal autoimmune disorder? Wahab et al. (10.1542/peds.2018-3933) investigated this question and share with us the results of their population-based cohort study of over 3,700 children who were tested for celiac disease at a median age of 6 years but were asked about behavior or emotional problems prior to having that diagnosis made. The results indicate that celiac disease autoimmunity was more likely to be found in children who had anxiety problems or oppositional defiant problems, and these children did not necessarily have gastrointestinal symptoms.
So what do the findings in this study mean? Should we be screening all children with behavioral disorders like anxiety for celiac disease in the absence of other gastrointestinal signs or symptoms? To make sense of the findings in this study we asked Drs. Smith, Kurppa, and Agardh, who have also been studying this association, to weigh in with a commentary. The authors note the similarities and differences of the Wahab et al. study and their own study also published in our journal (10.1542/peds.2018-3933). Despite some methodologic differences, we now have two studies that tie together emotional and behavioral problems with celiac disease, and yet as the commentary points out, while we need to keep celiac disease in mind when thinking about children with behavioral disorders, more studies are needed, such as whether improvement occurs with appropriate gluten-free diet, before we start screening more aggressively for celiac disease in patients who have no other symptoms. Digest the information in both the study and commentary, and at least keep celiac disease on your differential diagnosis list the next time one of your patients comes in with increased anxiety or an oppositional behavior problem.