Sabuncuoglu, O., Basgul, A., “Pregnancy health problems and low birth weight associated with maternal insecure attachment style”, J Health Psychol, 21, 934-943 (2016).

We aimed to determine the association between attachment style and health problems during pregnancy, as well as perinatal health variables. In 122 mothers who were 2-18 months postpartum, hot flushes, vaginal discharge, back pain, breast tenderness, hair changes, and psychological problems were shown to be associated with insecure attachment as measured by the Adult Attachment Style Questionnaires. Babies born to mothers with insecure attachment were more likely to have a low birth weight. It is vital to increase awareness of insecure attachment style as a risk factor among perinatal health care providers to optimize services.

Sabuncuoglu, O., “High Rates of Same-Sex Attraction/Gender Nonconformity in the Offspring of Mothers with Thyroid Dysfunction During Pregnancy: Proposal of Prenatal Thyroid Model”, Ment Illn, 7, 5810 (2015).

Both youngsters and adults with same-sex attraction are at greater risk for negative health outcomes. Despite mounting efforts to determine the biological background, a satisfactory conclusion has not been reached and there is a need to explore alternate factors like functioning of thyroid system during pregnancy. A retrospective chart review was undertaken of 790 eligible children and adolescents who had been admitted to child psychiatry between 2005 and 2013. This population consisted of 520 (65%) males and 270 (35%) females, aged 8 to 17 years. Fifteen mothers (1.8%) were found to have a history of thyroid dysfunction during pregnancy. Sixteen youngsters (2%) had a history of same-sex attraction. Twelve overlapping cases with both same-sex attraction and maternal thyroid dysfunction during pregnancy were identified, which was extremely significant (P<0.0001, by Fisher's exact test). The association was also significant for each sex (P<0.0001, by Fisher's exact test). There is evidence that thyroid gland plays a crucial and decisive role in determining sexual orientation in people. Maternal thyroid dysfunctions during pregnancy may result in homosexual orientation in the offspring.

Sabuncuoglu, O., “Comment on 'Temperamental and socioeconomic factors associated with traumatic dental injuries among children aged 0-17 years in the Swedish BITA study'”, Dent Traumatol, 31, 418 (2015).

Sabuncuoglu, O., Irmak, M.Y., Ucok Demir, N., Murat, D., Tumba, C., Yilmaz, Y., “Sibling Death after Being Thrown from Window by Brother with Autism: Defenestration, an Emerging High-Risk Behavior”, Case Rep Psychiatry, 2015:463694 (2015).

Children diagnosed with autistic spectrum disorders (ASD) may have serious behavioral problems such as aggression, self-injury, and violence. However, the literature on ASD either overrules any correlation between aggression and ASD or maintains the fact that the efforts to link them have so far been inconclusive. Although severe forms of violence are extremely rare in children with autism, there are a few cases reported in the literature with significant harm to siblings. We hereby report an 8-year-old boy with ASD who caused the death of his sibling by throwing her out of the window. Shared similarities of all defenestration cases indicate a pattern of high-risk behavior threatening the survival of minors. We recommend precautions against this high-risk behavior in children with ASD.

Sabuncuoglu, O., “Therapia, Istanbul”, Am J Psychiatry, 171, 732 (2014).

Sabuncuoglu, O., Orengul, C., Bikmazer, A., Kaynar, S.Y., “Breastfeeding and parafunctional oral habits in children with and without attention-deficit/hyperactivity disorder”, Breastfeed Med, 9, 244-250 (2014).

INTRODUCTION: Although children with attention-deficit/hyperactivity disorder (ADHD) were reported to have insufficient breastfeeding, consequences and oropharyngeal implications of this finding have not been studied. In this case-control study, we aimed to investigate early feeding practices and parafunctional oral habits in children with ADHD. SUBJECTS AND METHODS: The study group consisted of 200 children and adolescents, 7-17 years old, diagnosed as having ADHD at Marmara University Child Psychiatry Clinics in Istanbul, Turkey. The Conners Parent and Teacher Rating Scales were used to assess behavioral disturbances. A questionnaire was developed consisting of items pertaining to breastfeeding period, early feeding history, and parafunctional oral habits. The study data were compared with those for 175 healthy schoolchildren after exclusion of possible ADHD cases. RESULTS: The children with ADHD were found to have insufficient exclusive breastfeeding (less than 6 months) (p=0.0001). The children with insufficient exclusive breastfeeding were more likely to have a history of bottle feeding, longer duration of bottle feeding, and early introduction of bottle feeding (p=0.01). Overall, significant differences were detected on the domains of duration of bottle feeding, introduction of bottle feeding, introduction of pacifier use, variables of nail and toenail biting, as well as pencil biting, bruxism, and snoring between the ADHD group and the control group. CONCLUSIONS: The present results indicate that early in life, children with ADHD are subject to insufficient exclusive breastfeeding, different feeding practices, and elevated parafunctional oral habits more often than typically developing children. For all professionals who provide healthcare to children, increased awareness and attention to these factors are suggested.

Sabuncuoglu,O., “Understanding the relationships between breastfeeding, malocclusion, ADHD, sleep-disordered breathing and traumatic dental injuries”, Med Hypotheses, 80, 315-320 (2013).

Attention-deficit/hyperactivity disorder (ADHD), one of the most common neuropsychiatric disorders that present at young age, may occasionally be associated with physical problems and disorders. Among them exists a group of oral-pharyngeal conditions with considerable clinical morbidity. Previous research that identified absence or short duration of breastfeeding in ADHD children has been reviewed. Essential nutritional factors in breast milk can affect brain development and regulate the manifestation of ADHD symptoms. Low ferritin levels caused by insufficient breastfeeding may contribute to ADHD susceptibility because of the role of iron in dopaminergic activity. Insufficient breast feeding and subsequently excessive bottle-feeding may lead to increased rates of non-nutritive sucking habits, such as pacifier use and thumb-sucking, all of which are associated with the risk of development of malocclusions. Malocclusion refers to an unacceptable deviation from the ideal relationship of the upper and lower teeth and necessitates orthodontic treatment. Sleep-disordered breathing in children may present with neurocognitive symptoms that resemble ADHD and abnormal craniofacial developments, as well as malocclusions, have been cited as part of the syndrome. Obesity, which is an outcome of insufficient breastfeeding, is a shared comorbidity of ADHD and sleep-disordered breathing. The risk of traumatic dental injury is higher in children with ADHD and presence of malocclusions further increases the likelihood of dental injuries. In this review, certain oral-pharyngeal conditions relating to ADHD have been reviewed and links among them have been highlighted in a tentative explanatory model. More research that will provide increased awareness and clinical implications is needed.

Ekinci, O., Bez, Y., Sabuncuoglu, O., Berkem, M., Akin, E., Imren, S. G., “The association of music preferences and depressive symptoms in high school students: A community-based study from Istanbul”, Psychology of Music, 41, 565-578 (2013).

We investigated the association of music preferences with depressive symptoms among high school students in Istanbul; 10th-, 11th- and 12th-grade students (N = 1226) were chosen for the study. The Children’s Depression Inventory (CDI) and a detailed, semi-structured, self-report inquiry assessing music preferences and various psychosocial variables were administered to the students. Adolescents reporting heavy metal music and arabesque music in their playlists had significantly higher CDI total scores compared to adolescents who did not report these genres in their playlists. The percentage of students with problematic parent relations was highest for those with preferences for heavy metal music. Alcohol use was highest among students with preferences for dance/hip-hop music, followed by those with preferences for heavy metal. Negative thoughts and feelings when listening to music were related to higher CDI scores regardless of the favourite music genre. Future studies are needed to clarify the relationship between music preferences and specific psychopathologies in adolescents.

Ekinci, O., Topcuoglu, V., Sabuncuoglu, O., Berkem, M., Akin, E., Gumustas, F.O., “The association of tattooing/body piercing and psychopathology in adolescents: a community based study from Istanbul”, Community Ment Health J, 48, 798-803 (2012).

We aimed to investigate the association of psychopathology with tattooing and body piercing among adolescents in Istanbul by means of self-report questionnaires. Tenth, eleventh and twelfth grade students from 2 high schools in Istanbul with a total number of 607 participated in the study. The Youth Self Report, Children's Depression Inventory and a detailed semi-structured inquiry assessing tattooing, body piercing and some psychiatric and psychosocial variables were administered to the students. The prevalence of tattooing and body piercing were 4.8 and 7 %, respectively. The adolescents with tattooing and body piercing were found to have a higher frequency of alcohol and drug use, smoking, going to bars/night clubs and lower school grades when compared to those without tattooing and body piercing. Externalizing problems, mainly delinquent and aggressive behaviours were more prominent in the adolescents with tattooing and body piercing. Tattooing and body piercing in adolescents may be indicative of mental health risks.

Ekinci, O., Sabuncuoglu, O., “Psychosis associated with switching from risperidone to aripiprazole in an adolescent on methylphenidate treatment”, Prog Neuropsychopharmacol Biol Psychiatry, 35, 648-649 (2011).

Sabuncuoglu, O., Ekinci, O., Berkem, M., “Fluoxetine-induced sleep bruxism in an adolescent treated with buspirone: a case report”, Spec Care Dentist, 29, 215-217 (2009).

Sleep bruxism, the involuntary grinding and/or clenching of teeth during sleep, may occur in young children and may be secondary to medication use, especially selective serotonin reuptake inhibitors (SSRIs). The mesocortical disinhibition produced by SSRIs may lead to dopamine depletion that manifests itself as nocturnal bruxism, a specific form of akathisia. This may be prevented by using buspirone, a 5-HT1A agonist that reduces serotonergic activity and increases dopaminergic activity. This article reports on a case history of an adolescent with fluoxetine-induced bruxism that was successfully treated with buspirone. As SSRI use is on the rise for treating childhood psychiatric disorders, this case report highlights the importance of recognizing SSRI-induced bruxism and the possible related adverse dental side effects. Furthermore, this report supports the efficacy of a treatment strategy in adolescents, which has previously been reported only for adult patients.

Sabuncuoglu, O., “An Evaluation of Physician-Surgeon Serefeddin Sabuncuoglu’s Work in a Renaissance Perspective“, Salud Ciencia, https://www.siicsalud.com/dato/experto.php/98317 (2009).

The Turkish physician-surgeon Serefeddin Sabuncuoglu (1385-1470), who lived in northern Anatolia during the 15th century, is one of the most outstanding figures in the history of medicine. Despite a religious background prohibiting image-making at the time, he pioneered the use of illustrations in his surgery textbook, Cerrahiyetü’l Haniyye (Imperial Surgery). This well-known textbook, written in Turkish relies on classical sources and includes original additions. Throughout his work, Serefeddin Sabuncuoglu emphasized the importance of a humanistic approach of caring and acting in the best interest of patients. He was also one of the earliest physicians to use self-experimentation to prove the efficacy of a medication. Serefeddin Sabuncuoglu lived in a period when considerable overlap between the late middle ages and a flourishing Renaissance existed. The characteristics of Renaissance include a growing interest in classical sources, the application of humanistic ideas, new advances in arts, science and religion. In this article, taking the psychiatry-related illustrations as a starting point and elaborating on specific aspects therein, I aimed to investigate Serefeddin Sabuncuoglu’s work in a Renaissance perspective. Although he lived in a remote and unusual location to be associated with Renaissance, significant parallels were found.

Sabuncuoglu, O., "Re: Illustration by Serefeddin Sabuncuoglu as the Cover Art of the 15 May 2007 Issue of Clinical Infectious Diseases", Clin Infect Dis, 47, 146 (2008).

Sabuncuoglu, O., “Comment on ‘A Community Based Investigation of the Association Between Cannabis Use, Injuries and Accidents”, J Psychopharmacol, 21, 559 (2007).

Sabuncuoglu, O., “Risperidone-to-methylphenidate Switch Reaction in Children: Three Cases”, J Psychopharmacol, 21, 216-219 (2007). Erratum in: J Psychopharmacol, 22, 699 (2008).

As atypical antipsychotics are increasingly used in the treatment of childhood behavioural disorders either as monotherapy or in combination with other medications, there is a need to know more about their safety, in particular during switching to and from methylphenidate treatment, as antipsychotics and methylphenidate have opposing effects on dopaminergic neurotransmission. This report is about three cases of children who developed severe adverse reactions during switching from risperidone to methylphenidate. The first patient was a 6-year-old boy, diagnosed with attention deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). He developed severe hyperactivity and agitation on taking methylphenidate after the discontinuation of risperidone treatment. The second patient was a girl of 6, already on risperidone for ADHD and borderline intellectual functioning when referred. She displayed severe hyperactivity, agitation and irritability upon switching to methylphenidate medication. The third patient was a 15-year-old female adolescent with a similar clinical course as the previous patients. In all the cases described here, it is only with the discontinuation of methylphenidate that the adverse reactions resolved and readministration of methylphenidate in two patients did not produce any adverse effect after a drug-free interval. Functional regulation of certain neuroreceptors during risperidone treatment may lead to altered behavioural responses upon switching to methylphenidate. Thus, a drug-free interval is recommended in order to prevent adverse reactions.

Sabuncuoglu, O., “Traumatic Dental Injuries and Attention-deficit/hyperactivity Disorder: Is There A Link?”, Dent Traumatol, 23, 137-142 (2007).

Traumatic dental injuries (TDIs) constitute a major cause of morbidity among children worldwide. Both TDIs and attention-deficit/hyperactivity disorder (ADHD) are prevalent conditions with similar male-to-female predominance and similar age of presentation. While the commonest causes of TDIs have been identified as playground or sports accidents, a well-known feature of ADHD is accident proneness. Violence, another significant risk factor for TDIs, is more likely to be observed in conduct disorder, a common comorbidity of ADHD. Also, both TDIs and ADHD have been found to be associated with left-handedness. The presence of multiple dental trauma episodes (MDTE), as well as increased risk for non-dental injuries in children with TDIs indicates an underlying persistent condition, which resembles ADHD. Higher point prevalence of mental distress at age 30, found to be associated with increased lifetime prevalence of TDIs, may also be taken as an evidence of a background developmental disorder persisting into adulthood with various comorbidities. In conclusion, this review combines the results of several studies and explains the significance of ADHD as an underlying and predisposing factor for TDIs. Increased awareness and close collaboration between different disciplines involved are essential.

Sabuncuoglu, O., Berkem, M., “Bağlanma Biçemi ve Doğum Sonrası Depresyon Belirtileri Arasındaki İlişki: Türkiye’den Bulgular”, Türk Psikiyatri Dergisi, 17, 252-258 (2006).

OBJECTIVE:The present study aimed to investigate the association between depressive symptoms and attachment style in postpartum women in a non-western setting. METHOD:This study was carried out at the local health care centers in April 2004 among Turkish mothers within 2 to 18 months postpartum. A sociodemographic data sheet and the Turkish versions of Edinburgh Postnatal Depression Scale (EPDS) and Adult Attachment Style Questionnaire (AAQ) were administered to 80 mothers. RESULTS:On the EPDS, 30 % of the sample (n=24) displayed symptoms of depression with a cut-off score of >/=11. Postpartum depressive symptoms (EPDS >/= 11) were found to be associated with insecure attachment style (X2=4.42, p=0.035; X2=10.81, p=0.001 for Part 1 and Part 2 of AAQ, respectively). CONCLUSION:Maternal insecure attachment behavior, stimulated by the close relationship with the infant may contribute to the factors that may give rise to symptoms of depression. The present study, performed in a non-western country, confirms the results of the previous western studies suggesting a relationship between insecure attachment style and postpartum depression (PPD). Clinicians should pay particular attention to vulnerable women regarding their attachment style for early identification and treatment of PPD, either in western or non-western societies.

Sabuncuoglu, O., “Early Color Illustrations of Psychiatric Treatment Methods, as Drawn by Physician Serefeddin Sabuncuoglu (1385-1470)”, Am J Psychiatry, 163, 2071 (2006).   

Sabuncuoglu, O., Berkem, M., “The Presentation of Childhood Obsessive-compulsive Disorder Across Home and School Settings: A Preliminary Report”, School Psychology International, 27, 248-256 (2006).

This study aimed to determine the exact pattern of obsessive–compulsive disorder (OCD) symptoms in children displayed across school and home settings. Twenty-six school children (aged 7 through 17) with OCD were tested using the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), the Clinical Global Impression (CGI) – severity subscale and a questionnaire which consists of items serving to compare the symptoms between home and school settings. The mean obsession and compulsion subscores on the CY-BOCS were found to be 10.73 ± 3.14 and 10.88 ± 3.17, respectively, both summing up a Total score of 21.61 ± 5.52. The mean CGI-severity scores, rated for home and school settings were 4.42 ± 0.90 and 2.42 ± 1.13 respectively, indicating a strong difference in the presentation of OCD between those settings (t= 7.02, df = 50, p< 0.0001). No gender, diagnosis (pure versus comorbid) and age effect (7 to = 12 years versus > 12 to 17 years) was found on the CY-BOCS and CGI-severity subscale (Mann–Whitney U test, all p> 0.05). The presentation difference we have noted in this study is a significant finding. Further studies are needed to delineate the characteristics of this phenomenon with possible implications for diagnosis, management and treatment.

Sabuncuoglu, O., Taser, H., Berkem, M., “Relationship Between Traumatic Dental Injuries and Attention-deficit/hyperactivity Disorder in Children and Adolescents: Proposal of an Explanatory Model”, Dent Traumatol, 21, 249-253 (2005).

The objective of the present study was to determine the association between attention-deficit/hyperactivity disorder (ADHD) and traumatic dental injuries in a child psychiatric clinical population in Istanbul. A total of 475 consecutive children aged 8-17 years were enrolled in the study. Children and their parents were interviewed about the presence of traumatic dental injury and if a positive response was obtained further questions were inquired regarding the time and cause of the injury, and whether treatment had been sought. Child psychiatric diagnosis was based on Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria. Of the 475 children, 32 reported a traumatic dental injury (6.7%) with statistically significant association with ADHD (chi(2) = 26.90, d.f. = 1, P = 0.0001; odds ratio = 17.41, 95% CI: 4.11-73.55). On the Conners Teacher Report Questionnaire, children with dental trauma group differed significantly from the non-ADHD group but not from the ADHD group (F = 17.02, d.f. = 2, P = 0.0001). Among children with ADHD and dental fracture, the most common subtype was combined ADHD (90%). This is the first study describing a significant association between dental fractures and ADHD which contributes to an explanatory model on dental traumas among children. According to us, awareness of this association is essential at child psychiatry and pediatric dentistry settings and we recommend preventive efforts to be directed at the treatment of ADHD.

Sabuncuoglu, O., “Comment on ‘A Retrospective Study of Dental Behavior Management Problems in Children with Attention and Learning Problems”, Eur J Oral Sciences, 113, 184; author reply 184-185 (2005).