Fifty-two pediatric patients between 6–12 years of age admitted to the pediatrics outpatient department of the university hospital between May 2022 and February 2023 were included in this prospective study as the B12-deficiency group. Approval was obtained from the local clinical research ethics committee of Aksaray University in May 2022 before the study period (Protocol no: 2022/58-SBKAEK). Patients with additional vitamin deficiency, any chronic medical diseases, mental retardation, specific learning disabilities, autism spectrum disorder, bipolar disorder, any psychiatric disorders, and those having growth retardation and obesity were excluded from the study. After obtaining consent from the parents of the patients for the study, the children were divided into two groups under the level of vitamin B12 measured within the last month. The levels of vitamin B12 were measured with the UniCel™ DXI 800 immunoassay systems (Beckman Coulter, Brea, CA, USA).
Therefore, those diagnosed with vitamin B12 deficiency and for whom parental consent was obtained were included in the study. Given the characteristics of the control group, a total of 52 children between 6–12 years of age, admitted to the same department, with normal vitamin B12 levels measured in the last month and approval from their parents were selected as the control group. The Schedule For Affective Disorders And Schizophrenia For School-Age Children-Present And Lifetime Version, DSM-V November 2016-Turkish Adaptation (K-Sads-Pl-Dsm-5-T) was performed with the patients chosen for the criteria (18). While the parents of the patients were given the Conners' Parent Rating Scale-Revised Long (CPRS-R:L) and Barkley Child Attention Scale (BCAS) tests, their teachers were administered the Conners' Teacher Rating Scale-Revised Long (CTRS-R:L) and BCAS (5, 19–20).
The Conners’ Parent Rating Scale-Revised Long (CPRS-R:L)
The revised Conners' Parent Rating Scale-Revised Long (CPRS-R) is the standard tool to evaluate ADHD in children and adolescents. To make the scale simpler and clearer, the language has been updated, and items have been added, matching the symptoms for ADHD outlined in DSMV-IV. CPRS-R:L evaluates problematic behaviors as reported by parents or alternative caregivers and adolescents. Normative data for the revised forms arise from a large community-based sample of children and adolescents collected throughout the country where the scale is performed. While the norms are available for children and adolescents aged 3 to 17 on the parents’ rating forms, other norms are available for adolescents aged 12 to 17 on the self-report forms. The 80-item CPRS-R:L is composed of these subscales: oppositional, cognitive problems, hyperactive-ımpulsive, anxious-shy, perfectionism, social problems, psychosomatic, DSM-IV symptoms, ADHD index, and Conners’ Global index.
The Conners’ Teacher Rating Scales (CTRS-R:L)
The Conners' Teacher Rating Scale-Revised Long (CTRS-R:L) is the standard instrument to assess ADHD in children and adolescents. The language has been updated to make the items simpler and clearer. Additional items matching the symptoms of ADHD outlined in the DSM-IV-V have also been put into the scale. CTRS-R:L is used to evaluate problem behaviors as reported by the teacher and adolescents. Normative data for the revised forms comes from a large community-based sample of children and adolescents collected throughout the country where the scale is carried out. The norms are available for children and adolescents aged 3 to 17 on teacher rating forms, and other norms are available for adolescents aged 12 to 17 on the self-report forms. The 59-item CTRS-R:L consists of the following subscales: oppositional, cognitive problems, hyperactive-ımpulsive, anxious-shy, perfectionism, social problems, psychosomatic, DSM-IV symptoms, ADHD index, and Conners’ Global index.
The Barkley Child Attention Scale (BCAS)
The scale was developed by Russell Barkley in 2013 to measure the symptoms of SCT. The Turkish validity and reliability study of the scale was conducted by Baytunca et al. among children with ADHD. The four-point Likert-type scale is composed of 12 items and two subscales: sluggishness and daydreaming. Each SCT item is scored as follows: 1, never or rarely; 2, sometimes; 3, often; 4, very often. The sluggishness subscale consists of a total of seven symptoms, including decreased activity, lethargy, and slowness of behavior. In comparison, the daydreaming subscale consists of a total of five symptoms, including daydreaming, absent-mindedness, and mental confusion.
Statistical analysis
The IBM SPSS Statistics for Windows, Version 20.0. program was used to perform the statistical analyses. While the continuous variables were expressed as mean ± standard deviation (SC) and median (min-max), the categorical variables were presented as frequencies and percentages. Whether the data were normally distributed or not was examined with the Shapiro Wilk test and Q-Q plots. According to results, Nonparametric tests were chosen. Mann Whitney U test was used to compare two independent groups in terms of continuous variables, and Kruskal Wallis analysis of variance technique was used to compare more than two independent groups. The chi-square or Fisher's exact test was used to assess the homogeneity of the distributions among the categorical variables. Additionally, Spearman correlation coefficient and related p value was used to examine the relationships. In this way, monotonic increasing and decreasing relationships between variables were interpreted. A p-value of < 0.05 was considered as significant. (21)