DOI: https://doi.org/10.21203/rs.3.rs-2859119/v1
Background
Slow cognitive tempo (SCT) is a disorder characterized by two symptomatic dimensions: motor symptoms such as sluggishness and slow movement, and such cognitive problems as daydreaming, appearing sleepy, slowed behavior/thinking, and confusion. Albeit its unclear etiology, SCT is considered multifactorial, as in attention deficit hyperactivity disorder (ADHD). Here, we aimed to investigate the relationship between vitamin B12 deficiency, one of the conditions causing neurodevelopmental retardation, and SCT.
Methods
Diagnosed with vitamin B12 deficiency, 52 patients without additional vitamin deficiency and psychiatric diseases, and 52 controls without vitamin deficiency and any diseases were included in the study. While the Conners' Parent Rating Scale-Revised Long (CPRS-R:L) and the Barkley Child Attention Scale (BCAS) were performed with cases’ parents, their teachers underwent the Conners' Teacher Rating Scale-Revised Long (CTRS-R:L) and BCAS. The scores were also evaluated statistically.
Results
Among B12 deficiency patients, parental education was found lower, and the number of siblings was higher than controls. The risk of patients’ daydreaming scores with vitamin B12 deficiency was 1.4 times higher than that of the controls. Given the investigation of SCT concerning sluggishness and daydreaming scores, a significant difference was detected in terms of sex difference (p = 0.008), and girls were seen to have a higher total score.
Conclusion
In families with a higher number of siblings and a lower level of parental education, vitamin B12 deficiency is more commonly witnessed, and the symptoms of SCT should be considered to develop in those with B12 deficiency, without severe neurological and hematological findings.
Also known as sluggish cognitive tempo, slow cognitive tempo (SCT) is a disorder characterized by two main symptomatic dimensions: the motor symptoms, such as sluggishness and slow-moving, and such cognitive problems as daydreaming, appearing sleepy, slowed behavior/thinking, and confusion (1). Although such two main symptoms as attention deficit and hyperactivity disorder are the common symptoms seen in attention deficit hyperactivity disorder (ADHD) and SCT, it has been stated that ADHD and SCT are separate disorders and are not subgroups of each other, but can be seen concomitantly (2–4). Various studies indicated that the relationship between SCT and ADHD is mostly related to the inattention symptoms encountered in ADHD, but not hyperactivity-impulsivity symptoms, and while related to internalizing symptoms positively, the clinic of SCT is associated with externalizing symptoms negatively, and differentiates with ADHD (3, 5). Although the etiology of SCT has yet to be fully known, the etiology is considered to be multifactorial, as in ADHD; additionally, several studies examining the effects of genetic and environmental factors on SCT have been conducted so far. In a study investigating the effects of genetic and environmental factors on SCT, it was emphasized that while hereditary factors were moderately effective on SCT, environmental factors were further related to SCT, the symptoms of ADHD were affected by genetic factors at a higher rate, and ADHD was more hereditary than SCT (6). The symptoms of SCT have been revealed to be associated with such factors as prenatal alcohol consumption, prenatal and postnatal exposure to cigarette smoke, unemployment of parents, male gender, and low education level of mothers, and to be more frequently encountered in children with acute lymphoblastic leukemia (7–9). In another study, while a significant positive correlation was detected between the concentration of thyroid-stimulating hormone (TSH) and SCT symptoms, no correlation was determined between TSH concentration and ADHD symptoms (10). Such findings indicate that there is a need for further studies investigating the possible environmental and biological factors involved in the etiology of SCT (3).
The different types of vitamin B, such as vitamin B12, folate, and vitamin B6, play a key role in the synthesis of proteins, lipids, nucleic acids, neurotransmitters, and hormones (11). Vitamin B12 deficiency is a common nutritional deficiency and has been associated with a variety of neuropsychiatric disorders, including deterioration in memory, irritability, depression, dementia, and, rarely psychosis. In school-age children with B12 deficiency, however, the primary findings are seen as attention deficits, decreases in academic success, neglecting routine tasks, and increases in delinquent behaviors (12–14). In addition, vitamin B12 is a cofactor of the enzymes required for the metabolism of monoaminergic neurotransmitters, playing an important role in the etiology of ADHD. It has been demonstrated in various recent studies that as well as the deficiency of vitamin B12 in those diagnosed with ADHD, the supplementation of vitamin B12 also helps to reduce some ADHD symptoms in such patients (15–17).
Considering all those effects of vitamin B12 on memory and attention, it is suggested that the symptoms of SCT may be witnessed more commonly in patients with vitamin B12 deficiency. In the present study, therefore, we aimed to investigate whether there is a relationship between vitamin B12 deficiency and SCT.
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.
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)
In terms of socio-demographic characteristics, the only difference was found to be the paternal education level between B12 deficiency and control groups. Given the rates related to the paternal education level, the number of fathers graduating from a primary school was observed to be proportionally higher in the B12 deficient group (p = 0.041) (Table 1.)
Group with B12 Deficiency | Control Group | p | ||||
n | % | n | % | |||
Sex | Female | 24 | 46.15 | 26 | 50.00 | 0.845 |
Male | 28 | 53.85 | 26 | 50.00 | ||
Maternal Education Level | Primary | 22 | 42.31 | 14 | 26.92 | 0.232* |
Secondary | 16 | 30.77 | 16 | 30.77 | ||
High School | 10 | 19.23 | 17 | 32.69 | ||
Associate Degree | 0 | 0.00 | 2 | 3.85 | ||
Undergraduate | 4 | 7.69 | 3 | 5.77 | ||
Paternal Education Level | Primary | 12 | 23.08 | 3 | 5.77 | 0.041 |
Secondary | 16 | 30.77 | 19 | 36.54 | ||
High School | 18 | 34.62 | 17 | 32.69 | ||
Associate Degree | 0 | 0.00 | 0 | 0.00 | ||
Undergraduate | 6 | 11.54 | 13 | 25.00 | ||
Family Structure | Living with Family | 50 | 96.15 | 49 | 94.23 | 1.000* |
Separated | 2 | 3.85 | 3 | 5.77 | ||
Grades | Kindergarten | 4 | 7.69 | 2 | 3.85 | 0.743* |
Year 1 | 6 | 11.54 | 5 | 9.62 | ||
Year 2 | 8 | 15.38 | 13 | 25.00 | ||
Year 3 | 14 | 26.92 | 13 | 25.00 | ||
Year 4 | 12 | 23.08 | 14 | 26.92 | ||
Year 5 | 8 | 15.38 | 5 | 9.62 | ||
*Fisher’s exact test p-value. |
In terms of age, however, no significant difference was observed between the B12 deficiency and control groups (p = 0.512). Also, the number of siblings was significantly higher in the patient group (Table 2).
B12 Deficiency Group Mean ± SD | Control Group Mean ± SD | p | |
---|---|---|---|
Age (Years) | 9.06 ± 1.83 | 8.83 ± 1.75 | 0.512* |
Height | 131.98 ± 12.28 | 131.71 ± 11.72 | 0.909* |
Weight | 29.62 ± 8.36 | 30.81 ± 8.66 | 0.385 |
BMI | 16.64 ± 2 | 17.41 ± 2.6 | 0.140 |
Maternal Age (Years) | 35.63 ± 5.47 | 36.04 ± 5.92 | 0.725 |
Paternal Age (Years) | 38.62 ± 5.54 | 39.5 ± 5.88 | 0.481 |
Number of Siblings | 2.5 ± 1.02 | 2.02 ± 1.11 | 0.021 |
B12 Value | 86.04 ± 22.23 | 283.65 ± 61.51 | < 0.001 |
*Student’s t-test and all others Mann-Whitney U test. SD: Standard deviation |
The findings of CPRS-R:L showed no significant difference between the B12 deficiency and control groups, and the values compared in both groups are presented in Table 3.
CPRS-R:L | B12 Deficiency Group Mean ± SD | Control Group Mean ± SD | p |
---|---|---|---|
Oppositional | 6.94 ± 5.61 | 6.63 ± 5.32 | 0.801 |
Cognitive Problems/Inattention | 5.54 ± 6.39 | 5.4 ± 5.64 | 0.927 |
Hyperactivity | 5.23 ± 4.07 | 4.73 ± 3.85 | 0.564 |
Anxious-Shy | 16 ± 11.28 | 4.60 ± 4.07 | 0.339 |
Perfectionism | 4.81 ± 3.19 | 4.77 ± 3.19 | 0.965 |
Social Problems | 1.85 ± 2.07 | 1.75 ± 1.98 | 0.883 |
Psychosomatic Complaints | 3.15 ± 3.99 | 3.29 ± 3.69 | 0.715 |
ADHD Index | 7.54 ± 7.04 | 7.85 ± 6.38 | 0.661 |
Conners’ Global Index-Restlessness- Impulsivity | 4.19 ± 3.88 | 3.81 ± 3.11 | 0.865 |
Conners’ Global Index-Emotional Liability | 10.65 ± 9.13 | 9.83 ± 7.32 | 0.830 |
Conners’ Global Index-Global Total | 6.46 ± 5.37 | 6.12 ± 4.7 | 0.855 |
DSM-IV Symptoms Subscale-Inattention | 4.12 ± 4.71 | 3.96 ± 4.02 | 0.922 |
DSM-IV Symptoms Subscale-Hyperactivity and Impulsivity | 6.65 ± 5.57 | 6 ± 5.13 | 0.667 |
DSM-IV Symptoms Subscale-Total | 10.77 ± 9.71 | 9.96 ± 8.69 | 0.744 |
ADHD: Attention deficit hyperactivity disorder, CPRS-R:L: Conners’ Parent Rating Scale-Revised Long, DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, SD: Standard deviation |
The findings of CTRS-R:L were found to be statistically significantly different between the B12 deficiency and control groups in terms of the hyperactivity and impulsivity subscales of DSM-IV symptoms. The findings were observed to be higher in the B12 deficiency group (p = 0.023), and there was no statistical difference between both groups concerning other results (Table 4).
CTRS-R:L | B12 Deficiency Group Mean ± SD | Control Group Mean ± SD | p |
---|---|---|---|
Oppositional | 1.85 ± 2.23 | 2.04 ± 2.27 | 0.583 |
Cognitive Problems/Inattention | 3.13 ± 4.11 | 3.27 ± 4.1 | 0.822 |
Hyperactivity | 3.08 ± 4.46 | 2.56 ± 4.24 | 0.761 |
Anxious-Shy | 4.85 ± 3.27 | 5.25 ± 3.56 | 0.661 |
Perfectionism | 3.54 ± 2.25 | 4.12 ± 2.53 | 0.183 |
Social Problems | 1.4 ± 2.58 | 1.15 ± 2.55 | 0.379 |
ADHD Index | 7.5 ± 6.99 | 6.44 ± 7.57 | 0.425 |
Conners’ Global Index-Restlessness- Impulsivity | 2.29 ± 2.16 | 2.9 ± 3.8 | 0.942 |
Conners’ Global Index-Emotional Liability | 2.85 ± 2.55 | 2.71 ± 2.72 | 0.743 |
Conners’ Global Index-Global Total | 5.23 ± 5.33 | 5.06 ± 5.47 | 0.785 |
DSM-IV Symptoms Subscale-Inattention | 4.15 ± 5.69 | 4.21 ± 5.65 | 0.791 |
DSM-IV Symptoms Subscale-Hyperactivity and Impulsivity | 5.65 ± 5.64 | 3.83 ± 5.65 | 0.023 |
DSM-IV Symptoms Subscale-Total | 9.83 ± 9.88 | 8.04 ± 10.54 | 0.106 |
ADHD: Attention deficit hyperactivity disorder, CTRS-R:L: Conners’ Teacher Rating Scale-Revised Long, DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, SD: Standard deviation |
Given the findings of BCAS, the score of the daydreaming subscale in the B12 deficiency group was detected to be significantly higher in both CPRS-P:L and CTRS-R:L scales (Table 5).
BCAS | B12 Deficiency Group Mean ± SD | Control Group Mean ± SD | p |
---|---|---|---|
(Family) Daydreaming | 9.35 ± 3.59 | 7.6 ± 1.39 | 0.004 |
(Family) Sluggishness | 6.81 ± 2.74 | 5.58 ± 0.78 | 0.146 |
(Family) Total | 16.15 ± 6.12 | 13.17 ± 1.73 | 0.043 |
(Teacher) Daydreaming | 9.1 ± 3.27 | 7.62 ± 1.37 | 0.008 |
(Teacher) Sluggishness | 15.12 ± 2.18 | 14.5 ± 0.83 | 0.991 |
(Teacher) Total | 24.21 ± 5.18 | 22.12 ± 2 | 0.113 |
BCAS: Barkley Child Attention Scale, SD: Standard deviation |
When the sluggishness and daydreaming scores in terms of SCT were examined, it was seen that there was a significant difference between the two groups in terms of gender, but not in other parameters (p = 0.008), and the total score of the females was higher (Table 6).
Daydreaming | Sluggishness | CTRS-R:L TS | |||||
---|---|---|---|---|---|---|---|
p | 0.091 | 0.213 | 0.099 | ||||
Sex | Female | 8.34 ± 2.55 | 7 (7–9) | 15.18 ± 1.97 | 14 (14–15) | 23.52 ± 4.29 | 22 (21–24) |
Male | 8.37 ± 2.68 | 7 (7–8) | 14.46 ± 1.27 | 14 (14–14) | 22.83 ± 3.82 | 21 (21–23) | |
p | 0.892 | 0.008 | 0.252 | ||||
Maternal Education Level | Primary | 9.11 ± 3.62 | 7 (7-9.5) | 15.17 ± 2.18 | 14 (14–15) | 24.28 ± 5.61 | 21.5 (21–25) |
Secondary | 8.06 ± 1.56 | 7 (7–9) | 14.41 ± 0.76 | 14 (14–15) | 22.47 ± 1.97 | 22 (21-23.5) | |
High School | 7.48 ± 0.89 | 7 (7–8) | 14.74 ± 1.53 | 14 (14–15) | 22.22 ± 2.29 | 21 (21–22) | |
Associate Degree | 7.5 ± 0.71 | 7.5 (7–8) | 15 ± 1.41 | 15 (14–16) | 22.5 ± 2.12 | 22.5 (21–24) | |
Undergraduate | 9.43 ± 3.91 | 8 (7–10) | 15 ± 2.24 | 14 (14–15) | 24.43 ± 6.13 | 22 (21–25) | |
p | 0.304 | 0.896 | 0.809 | ||||
Paternal Education Level | Primary | 8.87 ± 3.54 | 7 (7–8) | 15 ± 2.45 | 14 (14–14) | 23.87 ± 5.89 | 21 (21–23) |
Secondary | 8.2 ± 1.53 | 7 (7–9) | 14.91 ± 1.58 | 14 (14–15) | 23.11 ± 2.68 | 22 (21–25) | |
High School | 8.83 ± 3.47 | 7 (7–10) | 14.94 ± 1.76 | 14 (14–15) | 23.77 ± 5.08 | 22 (21–24) | |
Undergraduate | 7.37 ± 0.5 | 7 (7–8) | 14.21 ± 0.54 | 14 (14–14) | 21.58 ± 0.84 | 21 (21–22) | |
p | 0.554 | 0.219 | 0.218 | ||||
Family Structure | Living with Family | 8.36 ± 2.66 | 7 (7–9) | 14.84 ± 1.71 | 14 (14–15) | 23.2 ± 4.14 | 22 (21–23) |
Separated | 8.2 ± 1.1 | 8 (8–8) | 14.2 ± 0.45 | 14 (14–14) | 22.4 ± 0.89 | 22 (22–22) | |
p | 0.246 | 0.477 | 0.286 | ||||
Grades | Grades .00 | 7.33 ± 0.52 | 7 (7–8) | 14.17 ± 0.41 | 14 (14–14) | 21.5 ± 0.84 | 21 (21–22) |
1.00 | 7.36 ± 0.5 | 7 (7–8) | 14.36 ± 0.67 | 14 (14–15) | 21.73 ± 0.79 | 22 (21–22) | |
2.00 | 8.52 ± 2.14 | 7 (7–10) | 14.52 ± 1.08 | 14 (14–14) | 23.05 ± 2.96 | 21 (21–24) | |
3.00 | 9 ± 3.95 | 7 (7–9) | 15.52 ± 2.56 | 14 (14–15) | 24.52 ± 6.33 | 21 (21–23) | |
4.00 | 8.04 ± 1.4 | 8 (7–8) | 14.46 ± 1.14 | 14 (14–14) | 22.5 ± 1.94 | 22 (21–23) | |
5.00 | 8.69 ± 3.12 | 7 (7–9) | 15.15 ± 1.63 | 15 (14–15) | 23.85 ± 4.65 | 22 (21–25) | |
p | 0.718 | 0.117 | 0.809 | ||||
CTRS-R:L TS: Conners' Teacher Rating Scale-Revised Long total score |
Since the daydreaming score showed a difference between the B12 deficiency and control groups, a logistic regression model was established, and effective risk factors for SCT were evaluated in the model. Accordingly, the risk of daydreaming scores of the group with B12 deficiency was found to be 1.4 times higher than that of the control group (Table 7).
B | SE | Sig. | Exp (B) | 95% CI for Exp (B) | |||
---|---|---|---|---|---|---|---|
Lower | Upper | ||||||
Constant | 2.532 | 1.055 | 0.016 | 12.582 | |||
CTRS-R:L-Daydreaming | 0.321 | 0.130 | 0.013 | 1.378 | 1.069 | 1.778 | |
Sex (Female) | 0.165 | 0.411 | 0.689 | 1.179 | 0.527 | 2.638 | |
CI: Confidence interval, CTRS-R:L: Conners' Teacher Rating Scale-Revised Long, Exp (B): Exponentiation of coefficient B, SE: Standard error, Sig.: Significance level |
The present study is composed of 52 cases diagnosed with vitamin B12 deficiency between 6–12 years of age and 52 healthy children of similar age as the control group. In the study, the scores of the vitamin B12 deficiency group obtained through CPRS-R:L filled by the parents, CTRS-R:L completed by the teachers, and BCAS completed by both the parents and teachers were compared with those of the control group. The daydreaming subscale scores of BCAS filled by both the parents and teachers were determined to be statistically significantly higher in the vitamin B12 deficiency group than in the control group. However, in terms of the sluggishness subscale of BCAS by both the parents and teachers, no statistically significant difference was found between the two groups. While the total scores of BCAS filled by the parents were found to be higher among the cases with vitamin B12 deficiency, no statistically significant difference was found between the B12 deficiency and control groups in terms of the total scores of BCAS filled by the teachers.
In many studies conducted in recent years, it has been revealed that vitamin B12 has impacts on the development and functions of the central nervous system, and vitamin B12 deficiency is a common nutritional deficiency playing a key role in the development of various psychopathologies. It has also been stated in those studies that B12 deficiency is related to cognitive deficits, and even borderline vitamin B12 deficiency also leads to the deterioration in cognitive functions in adolescents; low levels of vitamin B12 have been reported in children and adolescents with neurodevelopmental disorders such as ADHD and autism spectrum disorder (12, 13, 22–25). In addition, while a micronutrient supplement containing vitamin B12 has been shown to improve the symptoms of ADHD in children and adolescents, such a situation has not been emphasized in adults (22, 26, 27). In an animal study, however, early life was shown to be susceptible to dietary methyl donor supplementation, which can alter prefrontal cortex-dependent cognitive behaviors (28). As well as the abovementioned data, it was revealed in a genetic variation study that the gene variants of the folate-homocysteine metabolic pathway may be associated with the etiology of ADHD due to mild hyperhomocysteinemia and vitamin B12 deficiency. Although no studies have examined the relationship between SCT and B12 levels to date, there are numerous studies investigating whether individuals with ADHD have low levels of vitamin B12 (17, 24, 25). B12 deficiency is associated with the symptoms of attention deficits in ADHD and the clinical symptoms similar to those of SCT, such as lack of energy, sluggishness, and mental confusion (13, 17). Although SCT and ADHD have been reported to have similarities in terms of their symptoms, these two conditions are known to display different clinical pictures (2, 29).
In our study, the fact that the daydreaming subscale scores of BCAS filled by both the parents and teachers were higher in the vitamin B12 deficiency group than in the controls, and the scores of CPRS-R:L showed no significant difference between both groups suggests that B12 deficiency may be associated with SCT symptoms, rather than ADHD symptoms. In addition, when the regression analysis was performed, it was observed that vitamin B12 deficiency increased the risk of having a daydreaming score of BCAS 1.4 times higher, compared to the control group. In light of all these findings, it is considered that vitamin B12 deficiency may be involved in the etiology of SCT. Clinicians may be required to assess B12 levels in children with SCT symptoms, and the children with B12 deficiency may need an evaluation as regards the symptoms of SCT and neurodevelopmental disorders.
It was detected that the education level of the parents was statistically significantly lower, and the number of siblings was statistically significantly higher in the vitamin B12 deficiency group, compared to the controls (p = 0.041 and p = 0.021, respectively). Even so, in previous studies including contradictory findings, while some studies reported no relationship between the diagnosis of SCT, and age, gender, and ethnicity (30, 31). another study found a relationship between the severity of SCT symptoms, and advanced age and female gender. However, it has been shown that SCT may also be associated with low parental education and low household income (3).
Although the lower level of parental education and the higher number of siblings were significant in the vitamin B12 deficiency group compared to the control group, the familial education status and the number of siblings were seen to lead to no increased risks in terms of SCT, daydreaming and sluggishness scores in the regression analysis. In our study, however, when the sluggishness score was SCT was analyzed in terms of gender, the total score of females was observed to be higher (p = 0.008), meaning that female gender may be a risk factor for SCT.
Given our study limitations, the main limitation was that the study was designed and performed in a single center; so, study findings cannot be generalized to the whole pediatric population. Another limitation was that the findings were based on the teachers and parents’ self-reports, and the emotional reactions of the respondents may have been influenced by the children’s reactions. The limited number of participants can also be regarded as another limitation. However, we consider that the study may be a source of inspiration for clinicians in the differentiation between the symptoms of SCT and ADHD.
In conclusion, vitamin B12 deficiency, one of the factors leading to neurodevelopmental retardation in children, is a preventable condition that can be treated rapidly as soon as diagnosed, and it is so important to evaluate children in terms of neurodevelopment, screen for SCT symptoms, and accelerate the diagnosis process in suspected cases. In line with the data obtained in our study, therefore, it should be kept in mind that SCT symptoms may exist in those with vitamin B12 deficiency without severe neurological and hematological findings.
Ethics approval and consent to participate
The study was approved by ethics committee of the Aksaray University in May 2022 before the study period (approval number 2022/58-SBKAEK). Informed written consents were obtained by parents of patients.
All methods of this study were carried out in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.
Consent for publication
Not applicable.
Availability of data and materials
All data generated or analyzed during this study are included in this published article.
Competing Interests
The authors declare no conflict of interest.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.
Author Contribution
C.K.: design of the work; analysis, and interpretation of data; have drafted the work and substantively revised it. E.S.: design of the work; analysis, and interpretation of data. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
Acknowledgments
Not applicable.