Salivary cortisol responsivity to an intravenous catheter insertion in children with attention-deficit/hyperactivity disorder

Impact of IV-line Insertion on Salivary Cortisol Levels as a Stress Biomarker in Children

BACKGROUND: Children with leukemia will be treated for a quite long period of time that they will be subjected to multiple invasive procedures, one of which is IV-line insertion. This procedure can cause stress, which increases cortisol levels in the body. AIM: This study aimed to investigate how IV-line insertion affected cortisol levels as a stress biomarker in children. METHODS: This is a single-group pre-test and post-test design pre-experimental study. The study enrolled 30 children undergoing IV line insertion, aged from 6 to 18 years, who had not been eating or drinking for 30 min before the saliva sampling was scheduled to get IV-line insertion. The ELISA test was used to measure the salivary cortisol. If the difference in the cortisol levels is > 0.05 ng/ml, it is clinically significant. Furthermore, the Wilcoxon test was used to analyze the data. Cortisol changes were considered statistically significant if the p-value was <0.05. RESULTS: The cortisol levels were 3.43 (0.19–16.67) ng/ml and 4.14 (0.19–16.67) ng/ml before and after IV-Line insertion, respectively. The difference in the median was 0.71 ng/ml. The > 0.05 ng/ml difference indicates that IV-line insertion affects cortisol elevation. The Wilcoxon test showed a value of p = 0.34 (p > 0.05) indicating that IV-line insertion had no statistically significant effect on cortisol. CONCLUSION: Although an IV-line insertion does not have a statistically significant effect on cortisol, it clinically influences the increase of cortisol in children with leukemia.

Cortisol and inflammatory biomarker levels in youths with attention deficit hyperactivity disorder (ADHD): evidence from a systematic review with meta-analysis

Several studies reported abnormal cortisol and inflammatory biomarker levels in youths with attention deficit hyperactivity disorder (ADHD), but the results have not been conclusive. We conducted a systematic review followed by a meta-analysis of case-control studies assessing blood or saliva cortisol levels and blood levels of inflammatory biomarkers in youth with ADHD. The effect sizes (ES) were synthesized by using a random-effects model. In the 19 studies on cortisol levels (totaling n = 916 youth with ADHD and n = 947 typically developing (TD), healthy youth), youth with ADHD have lower basal cortisol levels at any time-points during the day (effect size: .68; p = 0.004) and lower cumulative levels of cortisol (ES: .39, p = .008) throughout the day than TD youth. Moreover, morning cortisol levels were lower in ADHD youth when compared with TD youth (14 studies, n = 1679, ES: .84, p = 0.003), while there is no difference for the afternoon cortisol levels (p = 0.48). The meta-analysis on inflammation biomarker was conducted on 4 studies (totaling n = 404 youth) showed that Tumour Necrosis Factor-alpha (TNF-α) was lower in ADHD when compared with TD (3 studies, n = 257 youth, p = 0.004), while no differences for Interleukin-1β(IL-1β) (p = 0.21), IL-6 (p = 0.09) and IL-10 (p = 0.77). The lower cortisol in the context of low TNF-α levels may indicate a specific pattern of biomarkers in ADHD, and further investigation is warranted.

Effect of music therapy on cortisol as a stress biomarker in children undergoing IV-line insertion

OBJECTIVE

An IV-line insertion can often provoke stress that can lead to an increase in cortisol levels. Complementary medication such as music therapy is needed to overcome the increase in cortisol levels. We conducted this study to determine the effect of music therapy on salivary cortisol levels in children with leukaemia undergoing IV-line insertion.

METHOD

This was a pre-experimental study with a pre- and post-test design. We analysed the salivary cortisol levels in 30 children with leukaemia undergoing IV-Line insertion from January until February 2018. Music was played using earphones after the completion of the IV-line insertion procedure. The salivary cortisol levels were analysed by an enzyme-linked immunosorbent assay (ELISA) test. Changes in cortisol levels were considered clinically significant if the differences were ≥0.05 ng/ml. The Wilcoxon test was used to test the effect of music therapy on cortisol levels and a p-value of <0.05 was considered statistically significant.

RESULT

Levels of cortisol before and after the music therapy had a median (min-max) of 4.14 (0.25-9.89) and 3.47 (0.16-15.31), respectively. The median difference of cortisol levels was 0.67 ng/ml. This change of ≥0.05 ng/ml indicates the clinical effect of music therapy on cortisol levels. Though the music therapy did not significantly affect salivary cortisol levels (p = 0.99), this study revealed the clinical effect of music therapy in reducing cortisol levels.

CONCLUSIONS

This study did not indicate a statistically significant effect of music therapy on cortisol levels of children with leukaemia during an IV-line insertion. However, the study findings reflect the clinical effect of music therapy in reducing cortisol levels.

Altered hypothalamus-pituitary-adrenal axis function: A relevant factor in the comorbidity of atopic eczema and attention deficit/hyperactivity disorder?

Epidemiological data show a significant association between childhood atopic eczema (AE) and an increased risk to develop attention deficit/hyperactivity disorder (ADHD). However, the underlying mechanisms of the comorbidity of AE and ADHD are mostly unknown. We investigated whether alterations of hypothalamus-pituitary-adrenal (HPA) axis function represent a shared feature of AE and ADHD potentiating AE-ADHD comorbidity. Children aged 6-12 years with AE, ADHD, or comorbid AE + ADHD and healthy control (HC) children were examined cross-sectionally (N = 145). To evaluate HPA axis function, salivary cortisol in response to psychosocial stress (Trier Social Stress Test for Children, TSST-C), after awakening (cortisol awakening response, CAR), and throughout the day (short diurnal profile) and hair cortisol capturing long-term HPA axis activity were assessed. Quantile regression analyses showed an attenuated cortisol response (% maximum change) to the TSST-C in children with ADHD compared to HC. A diminished cortisol response to acute stress was also observed in the comorbid AE + ADHD group, in which the reduction was numerically even more pronounced. Contrary to our previous findings, no alteration of the cortisol response to the TSST-C was observed in children with AE. However, in children with AE, increased ADHD-like behavior (i.e., inattention, impulsivity, and overall ADHD symptom severity) was associated with a reduced HPA axis response to acute stress. No such associations were observed in children without AE. Groups did not differ in CAR, short diurnal profile, and hair cortisol. These findings underscore the potential relevance of HPA axis function in the pathophysiology of AE and ADHD with emphasis on stress reactivity. Additional studies are required to further explore the separate and joint role of the HPA axis in the pathophysiology of AE and ADHD.

Genetic Variants and the Cortisol Response in Children: An Exploratory Study

OBJECTIVE

We examined genomic variation potentially associated with the cortisol stress response in children having a painful medical procedure.

DESIGN

Children 4-10 years old having a peripheral intravenous line inserted provided saliva samples for evaluation of the cortisol response as a biological measure of distress: two on the day of the procedure and two at home on a nonstressful day for comparison values. Children and biological parents also provided samples for genotyping of variants with known or suspected association with the cortisol stress response. Analysis included child-only association and family-based transmission disequilibrium tests (TDTs).

RESULTS

Genotype and phenotype data on the cortisol stress response were available from 326 children for child-only association analyses and 376 complete family trios for TDTs. Children were 50% female, an average of 7.5 years old, and mostly (83%) White/non-Hispanic. We identified four single-nucleotide polymorphisms (SNPs) potentially associated with the cortisol stress response: rs1176744 ( HTR3B), rs10062367 ( CRHBP), rs634479 ( OPRM1), and rs8030107 ( NTRK3). Family-based analysis identified a two-SNP haplotype in HTR1B suggestive for association with the cortisol response (rs6296, rs11568817). Allelic TDTs identified rs7897947 ( NFKB2) as potentially related to cortisol response.

CONCLUSIONS

Findings provide preliminary evidence for genes potentially important in cortisol response to an acute stressor in children in the serotonin, dopamine, and brain-derived neurotrophic factor pathways, the hypothalamic-pituitary-adrenal axis, and the inflammatory response. Combined with analyses of related phenotypes and clinical data, these results could help identify patients at increased risk of adverse responses to painful medical procedures who might benefit from tailored interventions.

A meta-analytic review of the association between cortisol reactivity in response to a stressor and attention-deficit hyperactivity disorder

A substantial literature suggests that abnormal cortisol reactivity may be a vulnerability for deleterious mental health outcomes, including ADHD. ADHD has been linked with difficulty in emotion regulation and increased risk of experiencing stressors, both of which may be related to psychobiological abnormalities (e.g., abnormal cortisol reactivity). Research has been mixed regarding the association between cortisol reactivity and ADHD. Therefore, the present meta-analytic review (k = 12) sought to quantify this association and review the relevant methodological issues and theoretical implications of this area of research. Overall, no effect was found between cortisol reactivity and ADHD (r = 0), although significant heterogeneity in the analyses suggested that there might be moderators of this association, if one does exist. Results highlight the importance of addressing limitations of the current literature on cortisol reactivity and ADHD and exploring additional indices of emotion regulation that may be associated with ADHD. Implications for future research efforts are discussed.

Salivary cortisol and alpha-amylase diurnal profiles and stress reactivity in children with Attention Deficit Hyperactivity Disorder

There is growing evidence for dysregulation of the stress system in individuals with Attention Deficit Hyperactivity Disorder (ADHD). The stress system includes neuroanatomical and functional components that function in concert to maintain homeostasis and its main effectors are the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic/adrenomedullary nervous system (SNS). As stress system activity demonstrates a distinct circadian variation, we aimed to describe simultaneously, diurnal rhythms of both the HPA axis and the SNS in children with ADHD and a comparison group. Moreover, we attempted to investigate stress responses to a physical stressor, venipuncture, in both groups. Sixty-two prepubertal children with ADHD combined (ADHD-C) or inattentive (ADHD-I) type and 40 typically developing children provided saliva samples at six specific time points during a day, as well as before and 10 min after a scheduled morning venipuncture. Salivary cortisol and α- amylase were selected as reliable noninvasive biomarkers for HPA axis and SNS function and were measured in the samples obtained. Results revealed that children with ADHD-C had lower mean cortisol values both 30 min after awakening and at 18:00 h than controls (p = 0.002 and p = 0.018 respectively), as well as lower mean Cortisol Awakening Response (CAR) and Area Under the Curve for "wake to bed" period (AUC_i) values of cortisol (p = 0.004 and p = 0.001, respectively). Also, mean CAR and cortisol AUC_i were lower in children with ADHD-I than the control group (p = 0.034 and p = 0.038 respectively). Alpha-amylase measurements showed an increase over time (p < 0.001), which was similar in all three groups. Interestingly, α-amylase changes over time were correlated with the corresponding cortisol changes (p < 0.001). Venipuncture, elicited a significant increase only in α-amylase levels and more so in the control group (p = 0.003). These findings suggest a partial hypofunction of the stress system in children with ADHD.

Thyroid and Cortisol hormones in Attention Deficit Hyperactivity Disorder: A case-control study

AIM

There is paucity of research in the putative role of hormonal biomarkers in Attention Deficit Hyperactivity Disorder (ADHD). The current study aimed to analyze the clinical profile, socio-demographic status, co-morbidity, hormonal biomarkers namely Thyroid hormones and Cortisol in children with ADHD and compare them with healthy controls and to explore the association of the hormonal biomarkers with severity of ADHD.

METHODS

Thirty children with DSM-IV TR diagnosis of ADHD were assessed using semi structured proforma, Conners' Parent Rating Scale revised short (CPRS - R: S) , Mini international neuropsychiatric interview for children and adolescents and Childrens' Global Assessment Scale as well as serum levels of total Triiodothyronine (T3) ,total Thyroxine (T4) , Thyroid Stimulating Hormone (TSH) and Cortisol using chemiluminescent immunometric assay and compared with 30 age- and gender -matched controls.

RESULTS

The typical profile of cases of ADHD was of a male with mean age of 9.47 years (S.D=2.43) belonging to Hyperactive subtype of ADHD. Serum T4 was significantly lower in cases compared to controls. No significant difference was found in serum T3, TSH and Cortisol levels. No significant correlation between the CPRS : R-S scores and the hormonal biomarkers.

CONCLUSIONS

There is need for exploration of Serum T4 as putative biomarker for ADHD with replication in future studies. It may also be important to report the negative finding of Cortisol as a biomarker of ADHD in the context of effective utilization of resources for research with special relevance to resource deficit developing countries.

The feasibility of salivary sample collection in an international pediatric cohort: The the TEDDY study

Saliva offers a relatively noninvasive method for measuring analytes such as cortisol, holding particular promise for use in pediatric populations on a large scale if a rigorous collection protocol is feasible in diverse settings. The Environmental Determinants of Diabetes in the Young study protocol, conducted in centers in the United States, Sweden, Finland, and Germany, used salivary collection to assess cortisol level as a physiologic marker of stress. Saliva was collected using Sorbettes from subjects at 3.5, 4.5, and 5.5 years of age. Parents collected a morning sample, and staff collected pre- and post-blood draw samples. Feasibility was assessed based on protocol completion, adherence with instructions, factors affecting adherence, and sufficiency of saliva sample for cortisol determination. Collection of saliva samples in a diverse pediatric population is feasible. Establishing non-invasive and acceptable methods for collecting physiological parameters of stress will allow better exploration of determinants of health in this important population.

Glucocorticoids enhance the in vivo migratory response of human monocytes

Glucocorticoids (GCs) are best known for their potent anti-inflammatory effects. However, an emerging model for glucocorticoid (GC) regulation of in vivo inflammation also includes a delayed, preparatory effect that manifests as enhanced inflammation following exposure to an inflammatory stimulus. When GCs are transiently elevated in vivo following exposure to a stressful event, this model proposes that a subsequent period of increased inflammatory responsiveness is adaptive because it enhances resistance to a subsequent stressor. In the present study, we examined the migratory response of human monocytes/macrophages following transient in vivo exposure to stress-associated concentrations of cortisol. Participants were administered cortisol for 6h to elevate in vivo cortisol levels to approximate those observed during major systemic stress. Monocytes in peripheral blood and macrophages in sterile inflammatory tissue (skin blisters) were studied before and after exposure to cortisol or placebo. We found that exposure to cortisol induced transient upregulation of monocyte mRNA for CCR2, the receptor for monocyte chemotactic protein-1 (MCP-1/CCL2) as well as for the chemokine receptor CX3CR1. At the same time, mRNA for the transcription factor IκBα was decreased. Monocyte surface expression of CCR2 but not CX3CR1 increased in the first 24h after cortisol exposure. Transient exposure to cortisol also led to an increased number of macrophages and neutrophils in fluid derived from a sterile inflammatory site in vivo. These findings suggest that the delayed, pro-inflammatory effects of cortisol on the human inflammatory responses may include enhanced localization of effector cells at sites of in vivo inflammation.

The aetiological association between the dynamics of cortisol productivity and ADHD

Attention-deficit/hyperactivity disorder (ADHD) has been linked to dysregulation of the hypothalamic–pituitary–adrenal (HPA) axis, indexed by salivary cortisol. The phenotypic and aetiological association of cortisol productivity with ADHD was investigated. A selected twin design using 68 male twin-pairs aged 12–15, concordant or discordant for high ADHD symptom scores, or control twin-pairs with low ADHD symptoms, based on developmentally stable parental ADHD ratings. A genetic growth curve model was applied to cortisol samples obtained across three points during a cognitive-electroencephalography assessment, to examine the aetiological overlap of ADHD affection status (high versus low ADHD symptom scores) with latent intercept and slope factors. A significant phenotypic correlation emerged between ADHD and the slope factor, with cortisol levels dropping faster for the group with high ADHD symptom scores. The analyses further suggested this overlap was mostly driven by correlated genetic effects. We identified change in cortisol activity over time as significantly associated with ADHD affection status, primarily explained by shared genetic effects, suggesting that blunted cortisol productivity can be a marker of genetic risk in ADHD.

A four-year follow-up controlled study of stress response and symptom persistence in Brazilian children and adolescents with attention deficit disorder and hyperactivity (ADHD)

This study evaluated children and adolescents with Attention Deficit Disorder andHyperactivity Disorder (ADHD), reassessing them at a four-year follow-up. Their cortisol response to a stress stimulus was measured twice. ADHD symptom persistence, development of comorbidities, and psychostimulant usage were also reassessed. The initial sample consisted of 38 ADHD patients and 38 healthy controls, age ranging 6-14. At the follow-up, there were 37 ADHD patients and 22 healthy controls, age ranging 10-18. ADHD was classified as persistent if the patients fulfilled all DSM IV criteria for syndromic or subthreshold or had functional impairment. Salivary cortisol samples were collected prior to the application of a cognitive stressor (Continuous Performance Test - CPT), and at three time intervals afterwards at baseline and at the follow-up. Their reassessment showed that 75% had persistent symptoms, psychiatric comorbidities (oppositional defiant and behavioral disorders), functional and academic impairement. Only seven patients were on medication. The ADHD group's cortisol levels were lower than those measured four years earlier, but cortisol concentrations were similar for both ADHD and control groups at the four-year follow-up. The cortisol results suggest that HPA axis reactivity could be a marker differentiating ADHD from ADHD with comorbidities.

Cortisol levels in children with attention-deficit/hyperactivity disorder

Regulation of the Hypothalamus-Pituitary-Adrenal axis (HPA-axis) and its end product cortisol differs among persons with certain psychiatric disorders when compared with controls. Some reports concern Attention-Deficit/Hyperactivity Disorder (ADHD) but findings are inconclusive. In this study we collected four saliva samples during a regular weekday in children, 6-17 years old, with ADHD (n = 201) and non-affected comparisons (n = 221). Saliva cortisol was measured with radioimmunoassay technique. Clinical data were collected for diagnostic information. Subtypes and severity of symptoms were determined using parental rating scales. Children with ADHD had lower saliva cortisol levels than comparisons at waking up Median = 9.1 versus 12.7 nmol/L (p < .001), 30 min later Median = 15.8 versus 20.1 nmol/L (p < .001) and before going to bed Median = 0.8 versus 1.0 nmol/L (p = .015). No difference was found for the afternoon sample. When the study group was split into three different age groups similar results were found only for children above 10 years of age. Subtype of ADHD or co-occurring symptoms did not affect the cortisol levels. Degree of severity of ADHD symptoms was not associated with cortisol levels in the study group, other than a weak negative correlation between the afternoon sample and hyperactivity symptoms. The low cortisol levels in children with ADHD may indicate a dysregulation of the HPA-axis, for instance a down-regulation or a phase delay of the diurnal curve. The low levels may be related to the under-arousal possibly underlying several of the core symptoms of ADHD.

Biomarkers and attention-deficit/hyperactivity disorder: a systematic review and meta-analyses

OBJECTIVE

To determine whether peripheral biochemical markers (biomarkers) might differentiate patients with attention-deficit/hyperactivity disorder (ADHD) from non-ADHD individuals.

METHOD

We conducted a systematic search and a series of meta-analyses of case-control studies comprising studies from 1969 to 2011.

RESULTS

We identified 210 studies in the following categories: 71 studies of the main metabolites and metabolism enzymes of monoaminergic neurotransmission pathway; 87 studies of environmental risk factors divided into heavy metals (18 studies), substance/chemical exposures (16 studies), and nutritional factors (trace elements: 29 studies; essential fatty acids: 24 studies); 22 studies of the hypothalamic-pituitary-adrenal axis (HPA) pathway; 31 studies indicated with "other". After screening for the availability for meta-analyses of drug naïve/free case-control studies and Bonferroni correction, five comparisons were statistically significant (Norepinephrine [NE], 3-Methoxy-4-hydroxyphenylethylene glycol [MHPG], monoamine oxidase [MAO], Zinc [Zn], cortisol), five of the significant findings found support in studies of response to ADHD medications (NE, MHPG, MAO, b-phenylethylamine [PEA], cortisol), six in studies of symptoms severity (NE, MHPG, MAO, ferritin, Zn, cortisol) and three in studies of neurophysiological or cognitive functioning (lead-ferritin-Zn). No evidence of publication bias was found, whereas significant heterogeneity of effect sizes across studies was found for three of the five biomarkers that differentiated ADHD from control subjects. Suggestive associations were evidenced for neuropeptide Y (NPY), manganese, and dehydroepiandrosterone (DHEA).

CONCLUSIONS

This study provides evidence for several peripheral biomarkers as being associated with ADHD both in diagnosis and in treatment efficacy. Further studies are warranted to replicate these findings, to assess their specificity for ADHD, and to quantify the degree to which they are sufficiently precise to be useful in clinical settings.