Research Article - Clinical Schizophrenia & Related Psychoses ( 2022) Volume 0, Issue 0
Assessment of Serum Ferritin Levels and RBC'S Parameters in Children with Attention-Deficit Hyperactivity Disorder (ADHD) and Learning disabilities (LD)Mohamed Khaled Mohamed Mokhtar1*, Lamis H Mekkawy2, Reham Ahmed Fahiem3, Hassnaa Othman Mohammed3, Walaa Ahmed Yousry Kabiel4 and Mostafa El-Nashar5
2Department of Pediatrics Neurodisabilities, Ain Shams University, Egypt
3Department of Phoniatrics, Ain Shams University, Cairo, Egypt
4Department of Clinical Pathology, Ain Shams University, Cairo, Egypt
5Department of Ear, Nose and Throat, Ain Shams University, Cairo, Egypt
Mohamed Khaled Mohamed Mokhtar, Department of Pediatrics, Helwan University, Cairo, Egypt, Email: [email protected]
Received: 07-Feb-2022, Manuscript No. CSRP-22-53647; Editor assigned: 09-Feb-2022, Pre QC No. CSRP-22-53647(PQ); Reviewed: 23-Feb-2022, QC No. CSRP-22-53647; Revised: 28-Feb-2022, Manuscript No. CSRP-22-53647(R); Published: 07-Mar-2022, DOI: 10.3371/CSRP.MMLM.030722
Objectives: Evaluation of serum Ferritin levels and RBC'S parameters among children with ADHD and LD children, using ferritin levels and RBC’S parameters in order to accept or reject the hypothesis of multifaceted nature of ADHD and LD.
Methodology: A sample of 40 children with ADHD and 40 cases with LD (case group) and 40 control children are subjected to assessment of serum Ferritin and RBC's parameters.
Results: Mean Serum ferritin level among ADHD and LD group were significantly different the mean value among the control group. CBC parameters among ADHD group and LD group (haemoglobin level, RBCs count, MCV and MCH) were significantly different from CBC parameters among the control group.
Conclusions: Serum ferritin and RBC's parameters were significantly lower in ADHD and LD patients compared to non-affected children, Conner test in ADHD was inversely proportional to serum ferritin level so Ferritin as an acute phase reactant gives better picture to iron store in ADHD and LD children so we must Increase screening of iron status and anaemia in ADHD and LD to start iron supplementation as early as possible to reduce symptoms of ADHD and LD patients.
Attention-deficit hyperactivity disorder • Ferritin level • Complete blood count • Learning disabilities
Attention Deficit Hyperactivity Disorder (ADHD) children represent (5%- 15%) of school-aged children, as the comments neuropsychiatric disorder worldwide, in both developing and developed countries . Thapar et al. reported that it could cause other disorders, academic difficulties, and social problems . ADHD children have long-term adverse effects on further social- emotional development, including peers, family members, and teachers .
ADHD and Learning Disability is a malfunction in the brain that causes difficulties in comprehension or processing information and causes by different factors . There are types of learning disorders include reading (dyslexia), writing (dysgraphia), and arithmetic (dyscalculia) . Literature among learning disabled showed that dietary allergy to certain food types may result in abnormal metabolic degradation which resulted in production of substances that may affect the vitamins absorption among these group of children. Besides being responsible for abnormal nutritional state it may result in many associated behavioural and academic poor outcome.
Iron is essential for many neurological functioning and development . Iron Deficiency (ID) is the most prevalent nutritional deficiency. Donfrancesco et al. showed that the risk of psychiatric disorders, ADHD, and developmental disorders was increased with ID .
Iron plays an essential role as antioxidants, homeostasis of the haemoglobin structure, genetic repair, and Central Nervous System (CNS) function. Ferritin is a stored form of iron that prevents the degrading effects of free iron .
Iron has many rules in early brain development, neurotransmitter function, and normal myelination. Deficiency of iron in prenatal or postnatal periods due to either mal-absorption and/or deficiency in dietary intake or subsequent Iron Deficiency (ID) may impair neurodevelopment and long-lasting cause irreversible consequences .
So we aimed to evaluate children with ADHD and learning disabilities; using ferritin levels and RBC’S parameters may help understand the multifaceted nature of ADHD and LD.
Materials and Methods
This study was a case-control study conducted on ADHD and LD children who attended paediatrics clinic in Military Production Hospital and Faculty of Postgraduate Childhood Studies, Ain Shams University, for over one year. The study was conducted on 120 subjects and was divided into two groups (case group and control groups). Cases groups consist of (group1: ADHD children, Group2: LD children) written informed consent was obtained from each participant before starting the study. Ethical approval was permitted from the Ethical Committee of Faculty of Postgraduate of Childhood Studies (FPGCS) at Ain Shams University, protocol no. RHDIRB2020110401.
a) Study group included forty ADHD children and forty children with learning disabilities subjected to DSM V criteria, and their age ranged between 5 and 17 years.
b) Control group included 40 healthy children, and their age ranged between 5 and 17 years.
All the groups were full filled the following:
• All children aged 5-17 years old.
• Diagnosis of ADHD (study group) based on Fifth Edition (DSM-V).
• Normal hearing
• IQ above 70 for ADHD and above 90 in LD children
• Normal motor activity for ADHD.
• Children with epilepsy
• Mental sub-normality, autism, organic brain lesions, psychiatric conditions, haematological disease, acute/chronic medical illnesses, or drug history were excluded during the last three months.
Physical examination: Including general examination with vital data assessment and general signs of iron deficiency such as weakness, extreme fatigue, tachycardia, shortness of breath, dizziness, and headache and local examination to exclude other factors affecting child growth and local signs of iron deficiency such as pale skin, cold hands and feet, and brittle nails. Anthropometric measurements including Weight (kg), height (kg) and Body Mass Index (BMI) [weight (kg)/height (m²)] were calculated.
Laboratory investigations: Including complete blood picture was done for all patients, and Serum ferritin levels were assessed by Enzyme- Linked Immune-Sorbent Assay (ELISA).
Sampling: Six millimetres of venous blood were collected under complete aseptic conditions from patients and controls. They were divided into two vacutainers as follow:
• Two millilitres (2 ml) were collected in a sterile EDTA vacutainer for a complete blood count. These samples were analysed immediately using Coulter Dx instrument for the differential count.
• Four millilitres (4 ml) of blood were collected in a sterile plain vacutainer and were left to clot for 30 minutes, and serum was separated by centrifugation at 3000 rpm for 20 minutes. The separated serum was stored at -20̊C. These serum samples were analysed for serum ferritin level using enzyme-linked immune sorbent assay (ELISA); the kit was supplied by a life technologies company (BIOS, Chemux Bioscience,Inc), Hemolyzed samples were discarded.
The ferritin Quantitative test kit is based on a solid phase using enzyme-linked immune sorbent assay (ELISA). The assay system utilized one anti-ferritin antibodies for solid phase (microtiter wells) immobilization and another mouse monoclonal anti ferritin antibody in the antibody enzyme (horseradish peroxidase) conjugated solution. The test sample was allowed to react simultaneously with the antibodies, resulting in the ferritin molecules being sandwiched between the solid phase and enzyme-linked antibodies. After 60 minutes incubation at room temperature, the wells were washed to remove unbound labelled antibodies. A solution of TMP was added and incubated for 20 minutes resulting in the development of a blue color. The color development is stopped with the addition of 2N HCL, and the color was changed to yellow and measured spectrophotometry at 450 nm. The concentration of ferritin was directly proportional to the color intensity of the test sample.
The mean absorbance value for each reference standard set, specimen, controls, and patient samples were all calculated. A standard curve was constructed on graph paper by plotting net absorbance values obtained from each standard on the vertical (y) axis against Ferritin concentrations in ng/mL on the horizontal (x) axis. The absorbance value of each sample was used to determine the corresponding concentration of ferritin in ng\ml from the standard curve.
The specificity of Ferritin kit was determined by measuring interference from high concentrations of human serum proteins (100 ug/dl, transferring; 1000 ug/dl, Ferric chloride, and 12 g/dl of albumin). No significant crossreactivity was observed.
All statistical calculations were done using computer programs and SPSS (Statistical Package for the Social Science) version 17. The qualitative data was expressed in the number (N) and personal Chi-square (X2) test. The quantitative results were expressed as means ± Standard Deviation (SD). An independent t-test was used to compare two groups, e.g. (obese versus normal weight - males versus females). They were finding the relationships between the quantitative variables done by Pearson correlation coefficient. The level of significance was considered at P-value ≤ 0.05.
Socio-demographic data of the three main groups (Table 1).
|Sex||Range of age in years (Mean)||P-value|
|Males No. (%)||Females No. (%)|
|Control||20 (50%)||20 (50%)||5-17 (8.7 years)||
|LD||18 (45%)||22 (55%)||5-17 (8 years)||
|ADHD||24 (60%)||16 (40%)||5-17 (8.15 years)||
Note: Chi-square test.
Comparison of CBC parameters among the three main groups (Table 2).
|MCH||26.57 (5.18)||24.43 (3.31)||0.043*||
|MCHC||27.27 (3.31)||23.65 (2.23)||0.012*||
|RDW||15.28 (1.63)||13.37 (1.53)||0.003*||
|Note: Unpaired t-test P value = 0.05 (non-significant), and *p-value<0.05 (Significant).|
Comparison of serum ferritin level between the three main groups (Table 3).
The mean Serum ferritin level of the ADHD group was 15.72 ng/dl while that of the LD group was 25.27 ng/dl, with statistically significant difference between their results and the mean serum ferritin level of the control group (45.4 ng/dl).
Comparison of CBC parameters and serum ferritin level between the three types of ADHD (Table 4).
three types of ADHD (Table 4). A mixed type of ADHD (type 3) showed the lowest serum ferritin level and CBC parameters. In contrast, inattentive type (type 2) showed better serum ferritin level and CBC parameters. Lastly, hyperactive type (type 1) showed the best and highest serum ferritin and CBC parameters scores.
Correlation between haemoglobin and ferritin levels in the three groups (Table 5) (Figure 1).
Regarding the ADHD group, serum ferritin level was directly proportionate to haemoglobin level, with a statistically significant difference between scores of both parameters. In the LD group, serum ferritin level was directly proportional to haemoglobin level, with no statistically significant difference between scores of both parameters.
Correlation between IQ score and serum ferritin level in the three main groups (Table 6) (Figure 2).
Regarding the ADHD group, serum ferritin level was directly proportionate to IQ scores, with a statistically significant difference between scores of both parameters. In the LD group, serum ferritin level was directly proportional to IQ scores with no statistically significant difference between scores of both parameters.
The main aim of this study was to evaluate the ADHD and to learn disabilities children; using ferritin levels and RBC’S parameters may help in understanding the multifaceted nature of ADHD and LD to achieve such goal. The control group in the study was selected to be age and gendermatched with the study groups. Our results showed no significant difference between both groups according to age and gender, so accordingly, both groups are matched, and the age and gender had no effect on the scores. ADHD and LD have different identities, but they may have some similarities in inattention and distraction. So, in this study, we try to find a link or hypothesis for them.
Kessler et al. mentioned that according to the DSM IV, ADHD children represent the symptoms before the age of seven . Therefore, the current work approximates the worldwide age of presentation of ADHD, which means age was eight years old. The diagnosis of LD requires persistent difficulties in one of the following or more: reading, writing, arithmetic, or mathematical reasoning skills during formal years of schooling (American Psychiatric Association) and that age were concurrent with the results of this study (Table 1) .
Although the gender was non-significant results statistically in ADHD and LD, these results were in concordance with Bellgrove et al. found that boys and girls are equally likely to have learning disabilities and ADHD . In disagreement with the Hawke et al. found that boys were two times affected than girls with ADHD .
In the current work, there was no statistical difference between males and girls with regards to LD. This was in agreement with Hicks et al. found no gender gap between boys and girls regarding learning problems . These results were against Lagae et al. found that boys are more likely to be diagnosed with learning disabilities than girls (12.9% compared to 5.6%) . The girl and the boy ratio varied by countries, ranging from 1:3 to 1:16. This proves that gender has no rule in L D manifestation or severity.
In the present study, group I: ADHD children and group 2: LD children were statistically significantly lower RBCs parameters than the control group (Table 2). These results were in concordance with Sungthong et al. found a correlation between the level of haemoglobin and LD; it was done on 192 LD children, their age ranged from 8 to 12 years old, they found that anaemia was present in 92 students (Hb from 10.0 g/dL to 11.5 g/dL) and the other 100 students (Hb from 14.0 g/dL to 14.9 g/dL) .
In the present study, the forty ADHD children had statistically significantly lower serum ferritin levels with a mean of 15.72 ng/dl than the control group with 30.43 ng/dl. Also, as regards the forty LD children had statistically significantly lower serum ferritin levels with a mean of 25.27 ng/ dl when compared to control (The serum ferritin<20 ng/dl is considered low) (Table 3).
These results, concordance with Pivina L et al. found that depletion in serum ferritin in children with cognitive and learning problems . Also, Soewondo S et al. found that the children with iron-deficiency anaemia performed significantly poorer in the achievement tests than those children who are non-anaemic .
Donfrancesco, et al. found that ADHD children had low magnesium, zinc, copper, and iron levels. Furthermore, iron is essential in dopaminergic regulation. ADHD is accompanied by dopamine releasers (amphetamine, psych stimulants and methylphenidate) . Karama S.et al. found a lack of dopamine, epinephrine, or norepinephrine in these areas of the brain is partly responsible for the symptoms experienced with ADHD patients .
Cortese et al., found in his study serum ferritin level in the ADHD group had statistically significantly lower serum ferritin level with a mean of 15.72 ng/dl compared to the control group with a mean of 30.43 ng/dl 6. This study found that type 3 mixed type of ADHD was the lowest serum ferritin level with a mean 14.44 (Table 4). In concordance with Calarge et al. who found that serum ferritin levels were inversely correlated with ADHD children with the lowest ferritin level the most hyperactive, impulsive, and inattentive .
Additionally, Sungthong et al. noted no association between serum ferritin and severity or frequency of ADHD in American ADHD participants aged between 5 and 16 years of age .
The relationship between ID and ADHD may be explained that ADHD could lead to academic difficulties and social problems; ADHD children have issues associated with deficits in language development and attention. There are several pathophysiological mechanisms, but the main cause is still vague. Low peripheral iron levels may dysregulate dopaminergic neurons, which results in multiple frontal dysfunctions in ADHD . In addition to the dopamine theory, the low ferritin level has an indirect rule in elevated oxidative stress, which is reported in ADHD children. This increased oxidative stress disturbs neurodevelopmental and gene functions and predisposing to the onset of ADHD .
Serum ferritin and RBC's parameters were significantly lower in ADHD and LD patients compared to non-affected children, so early treatment with iron supplementation is essential to reduce both symptoms of ADHD and LD patients. We hypothesized that lower iron status and RBCs parameter would accompany lower academic performance and behaviour problems also the most frequent local sign of iron deficiency in both ADHD and LD is pale of skin.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
The authors declare no conflict of interest.
- Thomas, Rae, Sharon Sanders, Jenny Doust and Elaine Beller, et al. "Prevalence of Attention-Deficit/hyperactivity Disorder: A Systematic Review and Meta-analysis." Pediatrics 135 (2015): e994-e1001.
- Thapar, Anita and Miriam Cooper. "Attention Deficit Hyperactivity Disorder." Lancet 387 (2016):1240-50.
- Jameson, Nicole D., Brooke K. Sheppard, Tarannum M. Lateef and Jennifer L. Vande Voort, et al. "Medical Comorbidity of Attention-deficit/hyperactivity Disorder in US Adolescents." J Child Neurol 31 (2016): 1282-9.
- Gates, Bob and Kay Mafuba. "Use of the Term 'Learning Disabilities' in the United Kingdom: Issues for International Researchers and Practitioners." Learning Disabilities: A Contemporary Journal 14 (2016): 9-23. [Crossref]
- Bradley, Renee, Louis Danielson and Daniel P. Hallahan. "Identification of Learning Disabilities: Research to Practice." England: Routledge, UK, (2002).
- Cortese, Samuele, Robin Azoulay, F. Xavier Castellanos and François Chalard, et al. "Brain Iron Levels in Attention-deficit/hyperactivity Disorder: A Pilot MRI Study." World J Biol Psychiatry 13 (2012): 223-31.
- Donfrancesco, Renato, Pasquale Parisi, Nicola Vanacore and Francesca Martines, et al. "Iron and ADHD: Time to Move Beyond Serum Ferritin Levels." J Atten Disord 17 (2013): 347-57.
- Doom, Jenalee R. and Michael K. Georgieff. "Striking While the Iron is Hot: Understanding the Biological and Neurodevelopmental Effects of Iron Deficiency to Optimize Intervention in Early Childhood." Curr Pediatr Rep 2 (2014): 291-8.
- Berner, A., M. Kamal, H. Z. Bener and D. Bhugra. "Higher Prevalence of Iron Deficiency as Strong Predictor of Attention Deficit Hyperactivity Disorder in Children." Ann Med Health Sci Res 4 (2014): 291-7.
- Kessler, Ronald C, Patricia Berglund, Olga Demler and Robert Jin, et al. "Lifetime Prevalence and Age-of-onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication." Arch Gen Psychiatry 62 (2005): 593-602.
- Peguero, Anthony A. and Jun Sung Hong. "Bullying and Youth with Disabilities and Special Health Needs: Victimizing Students with Physical, Emotional/Behavioral, and Learning Disorders." Berlin: Springer, Germany, (2020).
- Bellgrove, Mark A., Redmond G. O’Connell and Alasdair Vance. "Genetics of Cognitive Deficits in ADHD: Clues for Novel Treatment Methods." Expert Rev Neurother 8 (2008): 553-61.
- Hawke, Jesse L., Richard K. Olson, Erik G. Willcut and Sally J. Wadsworth, et al. "Gender Ratios for Reading Difficulties." Dyslexia 15 (2009): 239-42.
- Hicks, Carolyn. "Remediating Specific Reading Disabilities: A Review of Approaches." J Res Read 9 (1986): 39-55.
- Lagae, Lieven. "Learning Disabilities: Definitions, Epidemiology, Diagnosis, and Intervention Strategies." Pediatr Clin North Am 55 (2008): 1259-18.
- Sungthong, Rassamee, Ladda Mo‐suwan and Virasakdi Chongsuvivatwong. "Effects of Haemoglobin and Serum Ferritin on Cognitive Function in School Children." Asia Pac J Clin Nutr 11 (2002): 117-22.
- Pivina, Lyudmila, Yuliya Semenova, Monica Daniela Doşa and Marzhan Dauletyarova, et al. "Iron Deficiency, Cognitive Functions, and Neurobehavioral Disorders in Children." J Mol Neurosci 68 (2019): 1-10.
- Soewondo, Soesmalijah, M. Husaini and Ernesto Pollitt. "Effects of Iron Deficiency on Attention and Learning Processes in Preschool Children: Bandung, Indonesia." Am J Clin Nutr 50 (1989): 667-74.
- Karama, Sherif, Natalie Grizenko, Edmund Sonuga-Barke and Alysa Doyle, et al. "Dopamine Transporter 3'UTR VNTR Genotype is a Marker of Performance on Executive Function Tasks in Children with ADHD." BMC Psychiatry 8 (2008): 1-9.
- Calarge, Chadi, Cristan Farmer, Robert DiSilvestro and L. Eugene Arnold. "Serum Ferritin and Amphetamine Response in Youth with Attention-deficit/hyperactivity Disorder." J Child Adolesc Psychopharmacol 20 (2010): 495-502.
- Ghorayeb, Imad, Ashley Gamas, Zoé Mazurie and Willy Mayo. "Attention-deficit Hyperactivity and Obsessive-compulsive Symptoms in Adult Patients with Primary Restless Legs Syndrome: Different Phenotypes of the Same Disease?" Behav Sleep Med 17 (2019): 246-53.
- Kul, Muslum, Fatih Unal, Hasan Kandemir and Bahram Sarkarati, et al. "Evaluation of Oxidative Metabolism in Child and Adolescent Patients with Attention Deficit Hyperactivity Disorder." Psychiatry Investig 12 (2015): 361-6.
Citation: Mokhtar, Mohamed Khaled Mohamed, Lamis H Mekkawy, Reham Ahmed Fahiem and Hassnaa Othman Mohammed, et al. “Assessment of Serum Ferritin Levels and RBC'S Parameters in Children with Attention-Deficit Hyperactivity Disorder (ADHD) and Learning disabilities (LD).” Clin Schizophr Relat Psychoses 16S (2022). Doi:10.3371/CSRP.MMLM.030722.
Copyright: © 2022 Mokhtar MKM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.