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2009, Número S1

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Salud Mental 2009; 32 (S1)


Algoritmo de Tratamiento Multimodal para Escolares Latinoamericanos con Trastorno por Déficit de Atención con Hiperactividad (TDAH)

Peña OF, Barragán PE, Rohde LA, Patiño DLR, Zavaleta RP, Ulloa FRE, Isaac AM, Murguía A, Pallia R, Larraguibel M

Idioma: Español
Referencias bibliográficas: 108
Paginas: 17-29
Archivo PDF: 153.80 Kb.


RESUMEN

El desarrollo de algoritmos de tratamiento para escolares con TDAH de Latinoamérica se inició en el primer Consenso de la región celebrado en 2007, en la ciudad de México; este algoritmo incluyó sólo opciones farmacológicas. Después del segundo Consenso de la región celebrado en 2008, en la ciudad de Mendoza, Argentina, quedó clara la necesidad de incluir las intervenciones psicosociales, un algoritmo que permitiera ofrecer un tratamiento multimodal. El objetivo de este artículo es presentar, en forma actualizada y racional, las mejores intervenciones basadas en la evidencia científica para el tratamiento multimodal del TDAH en escolares.
Metodología: Se integró un panel de expertos con 10 especialistas de las áreas de psiquiatría, psiquiatría infantil y de la adolescencia y neuropediatría de seis países de Latinoamérica. Cada uno realizó un resumen de los temas establecidos y esos documentos fueron adaptados por el autor principal. Se partió de la base de una búsqueda bibliográfica amplia sobre el tratamiento del TDAH en escolares; los autores revisaron el documento y se generó un consenso para el documento final.
Resultados: Las intervenciones psicosociales incluyen: a) intervenciones familiares con psicoeducación y programas de entrenamiento a padres; b) intervenciones escolares con programas de entrenamiento para los maestros y asistencia académica, y c) intervenciones conductuales con entrenamiento en habilidades sociales. Las intervenciones farmacológicas se realizan con y sin estimulantes; se menciona la combinación de algunos medicamentos y el uso de otras opciones. También se describen el número y los resultados más importantes de las investigaciones controladas y los principales metaanálisis, y en algunos casos, el de estudios abiertos. El árbol de decisiones estuvo integrado por seis etapas básicas y dos alternas: la primera y la cuarta. En la Etapa 0 se consideran el diagnóstico y la psicoeduación básica. La combinación de las intervenciones psicosociales y farmacológicas se integró por medio de un consenso entre los autores; cada clínico podrá utilizarlas según la disponibilidad. En la Etapa 1 se recomienda usar estimulantes: metilfenidato o anfetaminas, y cambio de metilfenidato a otra presentación o forma de liberación. En la Etapa 1A, se aconseja continuar con estimulantes y ampliar la psicoeducación. En la Etapa 2, se recomienda el uso de atomoxetina. Durante la Etapa 2A se mantiene el uso de la atomoxetina y se incluye un programa de entrenamiento a padres; se realiza además una reevaluación diagnóstica. En la Etapa 3, se recomiendan la desipramina, el modafinil o el bupropión. En la etapa 3A se continúa con el medicamento previo y se inicia una intervención escolar. La Etapa 4 incluye la opción de los agonistas alfa adrenérgicos. En la Etapa 4A se continúa el uso de los agonistas alfa adrenérgicos y se deberá desarrollar un programa de entrenamiento en habilidades sociales para el niño; se realiza una nueva evaluación diagnóstica. En la Etapa 5 se requiere que un clínico experimentado realice la propuesta de combinación o sugiera otros medicamentos.
Conclusiones: El algoritmo para escolares latinoamericanos con TDAH recomienda la intervención conjunta y racional de medidas farmacológicas y psicosociales.


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