Celiac disease in children, psychiatrist Lucattini 'also affects psychological sphere'

Celiac disease is a chronic disease that requires strict adherence to a gluten-free diet for life. This can have a significant psychological impact on children and their families. The diagnosis can be a time of concern for parents and, depending on the age, also for the child. Adelia Lucattini, psychiatrist and psychoanalyst, full professor of the Italian Psychoanalytic Society and expert on children and adolescents, takes stock. At what age can the first symptoms of celiac disease generally appear in children? "Celiac disease is an autoimmune disease, the immune system reacts to gluten, a protein found in some cereals such as wheat, barley, rye and spelt. The immune system reacts to gluten by damaging the mucosa of the small intestine. This - the psychiatrist replies - causes inflammation, malabsorption of nutrients and various symptoms. The first clinical manifestations of celiac disease in children can appear between 6 months and 2 years of age, that is, after the introduction of gluten into the diet, usually through baby food, flour or bread".

"Knowing that children with celiac disease, if they follow a gluten-free diet as per medical practice, and are well followed and supported psychologically, grow up healthy, active, happy, fully integrated into social life and with excellent school results", Lucattini specifies. The classic symptoms of celiac disease "occur in a minority of celiac patients, while older children present minimal or atypical symptoms. Serological tests for celiac disease - he adds - must be performed in patients with unexplained chronic or intermittent diarrhea, growth retardation, weight loss, nausea, vomiting, chronic abdominal pain, abdominal distension, chronic constipation, recurrent aphthous stomatitis and abnormal increase in liver enzymes".

Do you think that cases of celiac disease in children have increased in recent years? "It is estimated that the prevalence of celiac disease in the general population is 1% worldwide. Its prevalence varies according to geographic and ethnic variations. The prevalence of celiac disease - you explain - has increased significantly in the last thirty years thanks to the greater knowledge and awareness of doctors and the widespread use of highly sensitive and specific diagnostic tests for celiac disease. Despite the greater awareness and knowledge of celiac disease, it is estimated that approximately 95% of celiac patients still do not receive a diagnosis. Recent studies indicate that the number of clinically diagnosed cases has increased in recent decades, in Italy there is a high prevalence, 1.65% among children in Italy, it affects females more frequently and is more frequent in Southern Italy".

In your opinion, what are the signs to pay attention to? "Classic symptoms in young children include: chronic diarrhea, poor growth (short stature, poor weight gain), swollen abdomen, irritability and insomnia, loss of appetite. However, increasingly - he observes - celiac disease presents in non-classical or atypical forms, even in school age or adolescence, with symptoms such as iron deficiency anemia, recurrent abdominal pain, constipation, headaches, mild or isolated growth problems, mood or behavioral disorders due to prolonged suffering from chronic physical pain. Nowadays celiac disease is considered a systemic disease that can cause growth retardation, short stature, delayed puberty, dental enamel hypoplasia, osteopenia/osteoporosis, iron deficiency anemia (from iron deficiency), recurrent stomatitis, dermatitis herpetiformis, arthralgia/arthritis even in the pediatric population with celiac disease. In addition, patients with celiac disease may present with a wide range of neurological symptoms such as headaches, paresthesia, neuroinflammation, and even psychological disorders such as phobia, anxiety and depression."

Could there be, in particular, a correlation between eating disorders and celiac disease? "The relationship between celiac disease and eating disorders appears to be bidirectional. In children with undiagnosed celiac symptoms, eating can cause abdominal pain, bloating and diarrhea, insomnia, all factors that can lead to a problematic relationship with food, due to the fear of feeling sick. To further complicate the relationship - warns Lucattini - there is the fact that anorexia nervosa and celiac disease share many similarities, including gastrointestinal symptoms and potentially fatal weight loss. The results of a research published in 'Psychiatric Times' (2025) showed that patients with celiac disease had an increased risk of 1.48 for anorexia nervosa even in childhood. Data on bulimia also show a potential correlation, in fact, in patients with celiac disease, the incidence of bulimia nervosa is just over 7%. It is also worth considering the complexity of treating celiac disease in a young patient who is already limiting food intake. In this regard, it is important to consult a team multidisciplinary team that takes full charge of the child with his physical and psychological pathology".

Can celiac disease also affect the quality of sleep in children? "According to a study published in the 'Journal of Clinical Sleep Medicine' (2023), sleep disorders are more frequent in patients with untreated celiac disease and tend to improve with the introduction of a gluten-free diet, regardless of gastrointestinal symptoms. This - continues Lucattini - suggests that there is a relationship between celiac disease and sleep disorders that can persist even if children are on a strictly gluten-free diet. This is for various reasons, celiac disease is still a systemic inflammatory disease for which children have reflux and stomach pain. Furthermore, food contamination is still too underestimated. It is known that flour flies and settles on food, in addition to this, it is essential to wash pots, dishes and cutlery very carefully, not only at home, but also at school and at friends' houses".

How important is sleep for children? "Sleep is essential for children's physical and mental health. Good sleep habits are linked to good mental functioning, better academic performance, better emotional regulation and quality of life. In contrast, shorter sleep durations have been associated with negative physical and mental health outcomes. Since sleep loss is associated with a wide range of difficulties and problems in many areas of life, its negative impact can have very serious consequences in children with chronic conditions. Early recognition of these problems can avoid negative consequences and improve the quality of life of children with celiac disease."

In these cases, can celiac disease lead to anxiety and depression in children? What are, in particular, the psychological factors that should not be underestimated? "The results of a study published in 'Psychiatric Times' (2025) showed that 39% of children with celiac disease, confirmed by biopsy, showed worrying levels of anxiety and depression - he observes - Scientific literature has found that patients with celiac disease have a 2.26 times greater risk of suffering from anxiety and a 3.36 times greater risk of developing depression. Depression and anxiety are consequences of physical suffering, of the attention to consuming gluten-free foods from an early age, of the difficulties of living with the physical symptoms of celiac disease, in fact a profound psychological manifestation of the condition itself. The results on attention deficit/hyperactivity disorder (ADHD) are not as solid as those relating to depression and anxiety, even if depression in childhood often presents itself as psychomotor agitation with attention difficulties.

According to the international guidelines, what is the most suitable diagnostic process to treat the disease? According to the ESpghan 2024 guidelines, the diagnostic process for celiac disease in children is structured to be accurate but as minimally invasive as possible. First of all, the symptoms presented by the child must fall within those known for celiac disease. Blood tests are significant if: there are high values ​​of anti-transglutaminase IgA antibodies (tTGA) greater than ten times the normal value; if there is positivity of anti-endomysial antibodies (Ema) in a second sample. Genetically - he observes - the presence of the Hla-DQ2 or DQ8 gene (which confirms genetic predisposition). If all these conditions are met, it is not necessary to perform an intestinal biopsy, otherwise it becomes (colonoscopy under sedation, the child must be asleep)".

Why can psychoanalytic support be important in managing celiac disease? "Psychoanalytic psychotherapy and analysis can play a valuable role in the management of celiac disease, especially in children and adolescents who experience the disease with emotional distress, internal conflict or difficulty in social adaptation. Celiac disease, in fact, is not just an intestinal disease, but can become a central element in the construction of the child's identity, of his relationship with the body, with others and with rules. Since celiac children develop anticipatory anxiety, a feeling of shame and avoidance, psychoanalytic psychotherapy allows us to work on these experiences and on the possibility of integrating the limit without being defined by it - suggests the psychiatrist - Psychotherapy helps the child and the family to rework the disease not as guilt or punishment, but as part of their own history. It can also support parents, who are often worried or uncertain about how to talk about the disease without transmitting anxiety and fear. Furthermore, it can help in social life, at school and with friends, since the child may feel excluded, different or limited (for example during snacks, parties, trips). A psychotherapeutic path can help him feel belonging to the group without denying his condition, thus developing resilience and increasing self-esteem. The management of celiac disease, once the indications and rules are understood, becomes a routine, lived with serenity".

What advice would you give to parents of children with celiac disease? "If you notice something wrong, even small changes in behavior, school performance, daily well-being and sleep, it is worth talking to your pediatrician and evaluating the possibility of doing specific tests for celiac disease - he highlights - Important: never start a 'trial' gluten-free diet before the diagnosis. The diet can distort the tests and delay the correct diagnosis. The diet must begin, if necessary, only on specific indication from the doctor; be a safe reference, without fear and without shame, capable of accompanying your child in accepting and managing his uniqueness; help your children with a specific nutritional education, making them actively participate and gradually teaching the rules of the gluten-free diet, in a playful way for the youngest and more informative for the older ones; as in all chronic diseases, celiac children - he concludes - need to be accompanied in their growth by psychoanalytic psychotherapy or analysis, which sometimes continues even during adolescence when they start going out with friends".