The current study retrospectively examined 134 medical records of patients diagnosed with autoimmune thyroid disorders, 103 (76.9%) females, and 31 (23.1%) males, who were following up in the Diabetes, Endocrine and Metabolism Pediatric Unit (DEMPU) at Abo El Rish El-Mounira Children’s Hospital, Kasr Al Ainy, Cairo University. The female/male ratio was 3.32/1, similar to a study by Karakaya et al. with a ratio of 3.5/1 [13] This was also demonstrated by similar studies with females having a higher ratio than males [14,15,16,17,18].

Goiter was the most common presentation in our patients with 26.1% followed by hyperthyroid symptoms (23.9%) and hypothyroid symptoms (13.4%). Also, some patients had both goiter and hyperthyroid or hypothyroid symptoms with 8.2% and 2.2% respectively. Similarly, a recent study conducted in Turkey showed goiter as the most common presentation with a percentage of 37.9% [13]. This aligned with another study conducted in China with goiter occurring in 21.1% of the patients [19]. Demirbilek et al., and Tunç et al. showed similar results with 54.9% and 43.5% of the cases of Hashimoto’s thyroiditis having goiter respectively [14, 18].

Cases presenting with hyperthyroidism and hypothyroidism were lower in some studies. A retrospective study conducted retrospectively on 119 cases between 2013-2020 described 21.8% having overt hypothyroidism and 4.2% having overt hyperthyroidism [13]. In addition, a study including 108 patients showed 16.6% having overt hypothyroidism and 3.7% having hyperthyroidism [14]. This also was the case in a study conducted on 19 patients with Hashimoto thyroiditis below the age of 3 years, which showed 16.6% having overt hypothyroidism (16.6%), and 3.7% having hyperthyroidism [19].

According to published research, between 40 and 70 percent of children with Hashimoto’s thyroiditis use L-thyroxine [20,21,22,23]. Levothyroxine was the most common medication taken in our patients in 46 (34.3%) of them. Our results were comparable to the results reported by Tunc et al, with 43.5% [14].

Hashimoto’s thyroiditis has a genetic predisposition. According to cohort research conducted in India, Hashimoto’s thyroiditis was nine times more likely to affect first-degree relatives of individuals with the condition than it was in the general adult population [24]. According to a different study, mothers with Hashimoto’s thyroiditis were 32 times more likely to pass on autoimmune thyroiditis to their children [25]. In our study, 34.3% of children had a positive history of autoimmune thyroiditis. This percentage was comparable to those reported by Karakaya et al., Tunç et al., Tang et al., Tuhan et al., and Wasniewska et al., with 36.1%, 59%, 47.4%, 47.5%, and 31.6% respectively [13, 14, 19, 26, 27].

Regarding the thyroid antibodies, 55.22% of children had positive anti-TPO Abs and 43.28% had positive anti-TG Abs. Our findings were lower than those reported by Tang et al. with anti-TPO Abs and anti-TG Abs being positive in 89.5% of their cohort, Tunç et al. with anti-TPO Abs positive in 95% and anti-TG Abs being positive in 87% of their cohort, and Karakaya et al, with anti-TPO positive in 87.5% and anti-TG Abs positive in 68.9% of their cohort [13, 14, 19]. This might be explained that antibodies were not done in all of our patients due to high financial cost.

As extracted from the records of the initial thyroid ultrasound done at the presentation, 76.4% of the patients had a goiter, 87.5% with a heterogenous pattern, 91.1% with increased vascularity, and 9 patients had pseudo-nodules. These findings were variable in several studies. Karakaya et al stated that 37.9% of the patients had a goiter and 11.1% had nodules in the thyroid ultrasound [13]. The percentage of goiter detected by thyroid ultrasound was 53.7% in the research carried out by Tang et al. [19]. Whereas, Tunç et al., reported goiter in 53.7% of cases with 88% having heterogenous parenchyma and 12% having homogenous [14].

Out of the 134 patients’ reports, 47 patients agreed to undergo psychiatric evaluation using the Strengths and Difficulties Questionnaire (SDQ) and Kiddle Quality of Life questionnaire. They were compared to 50 Healthy matched control children. Their SDQ assessment revealed a statistically significant difference between both groups regarding the emotional problem score, which was developed to evaluate mood, worry, fears, and mood-related somatic complaints. In the current study, the cases show higher emotional problem scores, which comes in line with a study conducted on patients with autoimmune thyroiditis in the euthyroid state, which supported that the risk of depressive and anxiety disorders was related to thyroiditis [28]. However, Hirtz and his team (2020) found that thyroid disease did not significantly affect the emotional state of children and adolescents who participated in their study [29].

The relation between autoimmune thyroid disorders and the presence of mood disturbances and emotional problems may be attributed to that autoimmune activity that stimulates the secretion of pro-inflammatory cytokines, which cause neuroendocrine and neurotransmitter alterations. The elevated levels of pro-inflammatory cytokines may be related to the activation of central inflammation [30]. Peripherally generated cytokines can cross the blood-brain barrier and impact neurogenesis in hippocampal neurons, which is thought to play a significant role in the pathogenesis of mood disturbances [31, 32].

Conduct problems in children and adolescents are a serious concern because of their relationship with long-term negative consequences such as antisocial behaviour and substance abuse. In our study, children and adolescents with autoimmune thyroiditis showed significantly higher scores in the conduct problem subscale in comparison to the control group which is in congruence with a study that assessed the effect of thyroid troubles especially autoimmune thyroiditis during pregnancy on adolescent offspring and they claimed an increase in oppositional defiant disorder and conduct behaviour among them [33]. In addition, there is a study in the adult population found a correlation between thyroid hormone levels and impulsivity and aggression in those who committed crimes [34]. On the contrary, a Turkish study reported that their study’s control group unexpectedly had higher scores on emotional and conduct problems subscales in comparison to the patients’ group [35].

Furthermore, our study discovered that the cases group had significantly more prosocial behaviour than the controls. Unlike other studies conducted by Berberoğlu & Görker, found no difference between the 2 groups regarding prosocial behaviour [36]. The explanation of increased prosocial behavior may be based on the concept”Altruism born of suffering”as prosocial activity stemming from a person’s bad experiences that make them more capable of giving and make them feel more responsible for preventing the pain of others [37, 38]. The negative experiences that children and adolescents with autoimmunethyroiditis may have include recurrent venipunctures for thyroid function measurement, medication adherence, and changes in appearance such as weight gain and hair loss. Moreover, regular clinic and hospital visits for follow-up and watching other children’s sufferings act as important factors in their prosocial behaviour development.

Regarding the quality of life, there were no statistically significant differences between cases and control groups except in physical well-being as patients showed lower physical well-being scores which are in contrast with research carried out by Uysal & Ayhan (2016), they found that autoimmune thyroiditis affects the subjective health status independent of thyroid function [39] (Uysal & Ayhan, 2016), this may be due to oxidative stress theory that can persist in autoimmune thyroiditis patients, causing cellular damage, decreased energy generation and exacerbating physical complains [40].

In the school activity domain, surprisingly, patients showed higher scores than the control group, which may be related to the high care and support provided by parents and teachers to help them cope with their peers.

Limitation

Our study was a retrospective study using patients’files. Also, less than half of the patients agreed to take part in the psychiatric assessment, so a relatively small sample underwent psychiatric evaluation. In addition, TSH receptor antibodies were not done as they are of limited availability and expensive. Also, not all patients did Anti-TPO and anti-TG antibodies; we were only able to diagnose autoimmune thyroiditis but not classify them to Hashimoto thyroiditis or Graves’ disease. In addition, some had negative antibodies, so diagnosis was made on strong clinical suspicion and ultrasonographic findings. Antibodies will be done for these patients in follow-up.

Recommendations

We recommend early and thorough psychiatric assessment of children with autoimmune thyroiditis and their prompt management and long-term follow-up. Also, to conduct this study on a larger scale and for a longer duration of follow-up.