Therapeutic and diagnostic ADHD Guide – Part I

Dr. Peter S. Jensen and Ms. Maura Crowe

 

Background
disorder attention deficit hyperactivity disorder (ADHD) is the most common behavioral / emotional disorder among school-age children and adolescents. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (Diagnostic and Statistical Manual of Mental Disorders [DSM-IV]) 1 defines ADHD as a disorder whose symptoms are inattention, hyperactivity and impulsivity. Prevalence rates vary from 3% to 12%, depending on the población.2,3 prevalence rates obtained from personal interviews are slightly lower than those based on lists of symptoms TDAH.4 Samples reference, the male / female ratio of ADHD varies from 3: 1-9: 1.
In contrast, in some population surveys, the pro-serving man / woman is lower, about 3: 1 to 4: 1. It is believed that adult and adolescent male / female ratio is equal. ADHD occurs in all socioeconomic, ethnic and cultural groups. Although the onset usually occurs in preschool age, many children are not diagnosed until they begin primary school. The girls are diagnosed later, perhaps because they tend to have fewer symptoms of impulsiveness
and hyperactivity children.
Diagnosis
To diagnose ADHD, the doctor must obtain a careful history of the parents and teachers of the patient, and other people who know the child. It is also important information regarding symptoms and function is obtained from several informants who live with the child in different scenarios. The physician should determine if the child meets the criteria for the diagnosis of ADHD according to
DSM-IV.1 must carefully rule out any other condition (eg, anxiety, depression and / or learning disability). Finally, the doctor must rule out any other explanation for the symptoms of ADHD possible.
This is achieved through a careful medical examination (includ-ing eye exams and hearing) by any necessary laboratory examination, and by psychiatric tests copedagógicas, when there is possibility of a problem
learning, intelligence or below the norm.
Behavioral lists that parents and teachers cumplimentan may help to establish the diagnosis, but should not replace the interview and careful medical history .
The DSM-IV specifies two categories of symptoms: inattention and hyperactivity / impulsivity nine symptoms listed in each category (Table 1). At least six of nine symptoms must be present in one or both categories to diagnose ADHD also had some symptoms have manifested before age 7 years old. Furthermore, the symptoms must have been present for at least nine months and should have caused a significant dysfunction in at least two settings (eg, home, school or peer group).
Classification
ADHD is classified into 3 types: (1) predominantly inattentive; (2) predominantly hyperactive-impulsive,
and (3) combined (both types of symptoms). Do not diagnose ADHD if symptoms occur only in the presence of a psychotic pervasive developmental disorder, schizophrenia or other psychotic disorder, or if they are better accounted for by another disorder psiquiátrico.4 In practice, this discrimination can be difficult. Following the difficulties of diagnosis, it generates confusion and controversy over-diagnosis, as problems were seen to discriminate between ADHD and bipolar disorder in children and youth.
Due to the great medical and public awareness General regarding ADHD, some people have questioned whether ADHD has not been diagnosed in exceso.5 However, a recent review concluded that there was little evidence on the diagnosis of TDAH.6 Some recent studies based on epidemiological sampling strategies have shown that, although some cases of “overdiagnosis” may present the biggest problem may be, in fact,
the “lack of diagnosis” 5.7 Since a variety of medical conditions and other psychiatric disorders can cause problems care, the physician should consider alternative diagnoses (Table 2), and diagnose ADHD symptoms only if no “are best explained with another mental disorder” 8
As a precaution, you should not assume that a positive response to treatment with stimulants ADHD is diagnosed as adults and children show normal cognitive and behavioral benefits when treated with estimulantes.9 Similarly, if the patient does not respond to stimulants, you should not remove the diag-nosis. Since some children, and the majority of adolescents with ADHD, can control their behavior and mos-strate good care at the doctor’s office, no symptoms at that stage not exclude the diagnosis. Then, it must be based on a medical history doso obtained care-parents, teachers and others who know the child well.
The interview with parents is the central component in the evaluation of possible ADHD. But still, it is necessary to interview school-aged children separately, ie without their parents. Both the interview with the parents and with the patient are used to rule out other causes of psychiatric and behavioral symptoms. The questions about the family history of ADHD,
other psychiatric disorders and psychological adversity
(eg poverty, family conflict, the psi-chopathology parents) are especially important
because of its relationship with the prognosis and that may suggest urgent need of combination therapy (medi-cines and behavioral therapy) for certain children.
Differential Diagnosis
The concurrent presence of other psychological medi-cos / psychiatric / disorders in children with ADHD is common. comorbidity is present in almost two-thirds or more of children with ADHD referred clinically, 10 with rates of 40% for Oppositional Defiant Disorder, 10% to 15% for conduct disorder, 30% to 40% anxiety disorders, and 5% to 25% for disorders of ánimo.10-12 Often, mental retardation and learning disorders confused with ADHD. Teachers themselves tend to do, but often it right with ADHD. Although clinical experience suggests that it is likely that children sent to centers specialized mental health pre-Senten more coexisting disorders that children are treated by pediatricians, comorbidity is more than the exception, even in epidemiologic studies of ADHD rule. These results suggest the need for careful evaluation by the presence of coexisting disorders in children with ADHD, even within the halls of primary care. If the doctor can not or is not qualified to diagnose possible comorbid conditions, you should re-mitir the patient to a specialist.
As a precaution, most comorbid conditions that were previously mentioned (anxiety, depressive disorders, learning disorders , etc.) not only they can be mistaken for ADHD, but can c
oexistir with him. Thus, the physician must determine not only whether these coin-cidencias best explain the problems the child has, but whether these conditions concur with ADHD.
Evaluation
The evaluation should take steps to obtain reports on behavior, attendance school grades and test scores. Sometimes, psychoeducational tests may be needed to assess the intellectual capacity and / or identify learning problems. The use of standardized measurement scales can contribute to the evaluation process more efficient, systematic and comprehensive. (Table 3 shows several commonly used scales. Note that these scales should not be used to diagnose the patient).
They must get behavioral lists both parents and several teachers, when possible. Lists commonly used are the Conners Scale Parent Reports (Conners Parent Report Scale), the Conners Scale Reports of Teachers (Conners Teacher Report Scale), the Programme for DSM-IV Personality adapted and maladjusted (DSM-IV Schedule for nonadaptive and Adaptive Personality), 10 and Barkley Situational questionnaires for Home and School (Barkley Home and School Situations Questionnaires). If some of the reports differ, the assessor must determine the cause of these differences and, when possible, should try to reconcile the sources and get the most valid information. If there is no apparent reason for the discrepancies reported, you should give more weight to the assessment by (n) (s) person (s) who knows (n) the child better. In general, it has been reported that teachers-ing provided more precise information on the behavior of ADHD in school, and are better able to differentiate a drug placebo activo.13 However, it is possible for parents to know the side effects better than the teachers, and observe concurrent disorder behaviors challenging oppo-sition, many children with ADHD have.
Medical Evaluation
A medical evaluation by a physician and peda-gogical and a complete physical examination are necessary if history has not been made A recent review like. The medical history should establish the presence or absence of all symptoms of ADHD and other concurrent disorder. The physical examination should include development testing, eye exams and hearing tests. Laboratory tests are only required for periodic health assessments. Although many tests have been proposed as part of the assessment of children with possible ADHD, there is no specific test for this tratorno.
So far, measurements of lead levels
in blood and thyroid levels, and analysis hair or nutrition have not demonstrated reliability.
The electroencephalograms (EEGs), brain mapping and / or neurological consultation may be indicated if there are reasonable concerns about the possibility of the presen-tation of attacks or some other neurological condition.
computerized EEGs, computerized photon emission tomography, positron emission tomography, magnetic resonance imaging, functional MRI scans and other tests to measure unem-per- activity levels have no diagnostic value. Today, the direct interview and a careful history to establish the presence of symptoms are the “gold standard” for diagnóstico9,14 However, these methods are useful research tools.
etiological factors
Although many possibilities have been proposed, the precise cause of ADHD is unclear. Some data suggest that no-converging multiple causes, which vary from child to child. Some studies have suggested that alte-rations in the noradrenergic system and / or dopamine are related to the pathophysiology of TDAH.9,15,17 Genetic factors are also important in the emergence of ADHD, since studies indicate a match to 90% among twins monocigóticos.16 It is thought that other factors favoring the onset of ADHD are prenatal and perinatal difficulties, cranio-encephalic trauma and the fact that the mother has smoked dur-
ing the embarazo.16
Treatment Approach
The most widely used treatment for ADHD, and most widely studied is the use of stimulants, including methylphenidate in various forms and application systems, amphetamine, dextroamphetamine and various combinations of amphetamine salts. Methylphenidate is the most widely used agent and is available in short and prolonged drug action (Ritalin, Ritalin-SR, Concerta and Metadate CD). In their respective forms of short acting, dextroamphetamine has a longer effect than methylphenidate. Dextroamphetamine (Dexedrine, Dexedrine Spansules), methamphetamine (Desoxyn) and a combination of amphetamine-dextroamphetamine (Adderall) are amphetamine-type compounds that are currently available. If a stimulant does not work, you should try another before switching to another class of drugs. Increasingly, the use of pemoline (Cylert) due to reports of liver failure associated with its use is restricted.
It should be noted that 95% of children with ADHD show a reasonable response to one of these stimulants. If the doctor wants to can raise the dosage as needed, when there is no clinical response or side effects, and if he or she continues to seek an appropriate drug if the first drug used has not worked. Although the drug is an important part of treatment, post itself does not represent the best approach to change the behavior of children, according to information provided by the study by the National Institute of Studies on Multi-modal Treatments for Mental Health Children with ADHD (Institute of Mental Health Multimodal Treatment Study of Children with ADHD [MTA]). In addition, parents often prefer behavioral alone or in combination with approaches-ledge is medicamentosos.10
Although it has been shown that stimulant ADHD patients benefit (Table 3), it has not been proven to correct all conditions associated with this disorder .18
The data that the MTA study has shed have shown various aspects of the drug that seem to produce better results with drug treatments. Therefore, the goal of health for drug titration should be to find the dose of medication that “normalizes” the child’s behavior and not to use the lowest possible dose. The MTA study showed that the most effective drug treatments were based on adjusted your medicine to the point that their conduct go unnoticed by his classmates. As a result, the drug dose used MTA strategy that are slightly higher than those generally administran.10 community physicians Moreover, estra-tegy most effective dosage of MTA used TID dosing approach, in contrast methods least successful drug treatment administered to the commu-nity is generally based on a BID dosing. Finally, more precise dose adjustments can be made ​​based on the information the teacher and not the parents. Therefore, to maintain constant communication with the teacher do to adjust the
daily dose as it is ne-sary seems to give more results than rely only on reports of padres.10
Other agents for which there is information that controlled clinical trials support its use include tricyclic antidepressants (TCAs) and bupropion.19 Thus, TCAs such as desipramine (Norpramin), imipramine (Tofranil) and nortriptyline (Pamelor), have shown efficacy in the tra-treat- ADHD. In general, TCAs should be used for patients who do not respond to stimulants or who have side effects. They have reported several cases of sudden death in children taking TCAs (prin-marily desipramine), possibly due to cardiac effects. Consequently, when TCAs are used for children with ADHD, current guidelines suggest that medical use low doses, EEGs performing baseline and periodically monitor cardiac parameters and levels of ATC in blood.14
Several Controlled trials performed in multiple centers, has shown that bupropion (Wellbutrin), a single antidepressant in its class, is moderately effective in treating ADHD. Moreover, recent information-lada compilation based on a meta-analytic review of all available studies on clonidine (Catapres) suggests that it is possible to have a moderately effective in treating ADHD. The drug may have some use in the treatment of some patients with ADHD, par-ticularly in those who show signs of opposition-aggressive-impulsive or insomnia. Guanfacine (Tenex), another a2-noradrenergic agonist, has a half-life pro-long-standing and is not as sedating as clonidine.
The main adverse symptoms associated with the use of stimulants are headaches, stomach aches, anorexia, insomnia, irritability, and rebound phenomenon. Less common side effects are crying, depression, sadness, tics and social isolation. More rare side effects include alopecia (methylphenidate), rashes, psychosis, exacerbation of Tourette syndrome, hepatitis (pemoline) and leukopenia and / or anemia (methylphenidate, pemoline). The potential contraindications in the use of stimulants include previous allergic reactions, marked anxiety, tension, agi-tion, psychosis, glaucoma, history of drug abuse, hyperthyroidism, severe hypertension, arteriosclerosis and vascular dis-eases. They should also take precautions with patients with mild cases of hypertension in women who are nursing or pregnant, and patients suffering tie-ques. Finally, despite the concerns expressed by the media, there is no data to support the idea that treatment with stimulants increase the risk of future substance abuse.
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