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Órgano Oficial del Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz

2009, Number S1

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Salud Mental 2009; 32 (S1)

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

Palacio JD, Ruiz-García M, Bauermeister JJ, Montiel-Navas C, Henao GC, Agosta G

Language: Spanish
References: 113
Page: 3-16
PDF size: 166.30 Kb.


ABSTRACT

Introduction: During the first Latin American ADHD consensus held Mexico in 2007 a treatment algorithm for attention-deficit/hyperactivity disorder (ADHD) in preschoolers was propose. Since then, some studies have emerged regarding not only pharmacological treatment, but also psychosocial managing strategies for this population that require a review. The main objective was to review the recent literature on preschool ADHD clinical management in order to update the treatment algorithm and to include together both psychopharmacological treatment and psychosocial management strategies into the decision tree.
Method: A task force with six experts from five Latinamerican countries was constituted. The task force included different health specialties: child and adolescent psychiatry, neuropaediatrics, psychology and neuropsychology. Literature in the field of preschool ADHD, published between 2006 and 2008, was reviewed, and the evidence level of studies was assessed, to develop the Multimodal Treatment Algorithm for Preschool ADHD in accordance with the Latin American population needs. From the gathered information, the experts elaborated the main recommendations for the assessment and management of ADHD Latin American preschoolers, and constructed the decision tree according to the evidence level of each treatment intervention.
Results: ADHD is among the most common neuropsychiatric consultations in preschool-aged children. There are five studies in Latin America showing a preschool ADHD prevalence between 3.24% and 11.2%. The main clinical manifestations are mostly related with poor impulse control, difficulty to follow simple instructions, overactivity and, in some cases, aggression and rejection by peers. Many studies show a high comorbidity with oppositional defiant disorder and other neuropsychiatric disorders, such as language, learning and motor disorder and anxiety and depression as well. The ADHD clinical presentation in preschoolers has the same severity level and comorbidity as in school age children, and it requires comprehensive treatment. There are some helpful scales to assess ADHD preschool children, such as the Parent and Teacher versions of the Conners Rating Scale, the IDC-PRE Scale, and the Early Childhood Inventory- 4. A diagnosis of preschool ADHD requires patient fulfilling DSM-IVTR criteria. Special recommendations made by the Latin American Multimodal Treatment Algorithm for Preschool ADHD group were: 1. to guarantee a minimum duration of ADHD symptoms of nine months; 2. to verify the report of symptoms directly with teachers; 3. to obtain clear-cut impact and repercussion criteria for «clear evidence of clinically significant impairment in social, academic, or family functioning»; severity is more important than the number of symptoms, and finally; 4. to rule out a list of different disorders mimicking ADHD, and also to detect factors and psychosocial situations influencing the ADHD presentation. There are several alternatives for the preschool ADHD treatment, population, which were inserted in the decision tree according to their evidence level. The Latin American Multimodal Treatment Algorithm for Preschool ADHD group recommends the integrated and rational use of both pharmacological and psychosocial treatments. Psychosocial treatments for the ADHD preschooler with good clinical evidence are: psychoeducation, parental management training (PMT), parentchild interaction therapy (PCIT) and behavioral school-based intervention. After parental assessment on ADHD knowledge, parent’s psychoeductation promotes good information about ADHD, and also gives parents guidance and support. There are some published studies about the efficacy of PMT and PCIT in Latin American preschool population. These therapeutic interventions help families to learn how to manage their children difficulties and improve family functioning. PCIT was designed for 2-7 year old children; it has a clinical orientation and involves the child, parents, and other family members in the treatment. Recent studies show a robust response to the PCIT reducing the ADHD symptomatology. Finally, behavioral school-based intervention has some evidence, and its implementation includes teacher training in contingency management plans in order to promote children self-regulation.
Methylphenidate (MPD) is the most studied psychopharmacological agent in this young population. Due to its robust clinical evidence, it is the first-line agent for the treatment of preschool children with ADHD. The group for the development of the Multimodal Treatment Algorithm for Latin American Preschool ADHD recommends to start with low doses of MPD, 1.25–2.5 mg/day, and gradually increase them every 2-3 weeks, until the maximum dose of 2.5-7.5 mg/day is reached. There are only two open-studies showing atomoxetine efficacy in this population. Atomoxetine has a medium evidence level and further studies are needed for more conclusions. The group recommends the use of atomoxetine with a maximum dose of 1.25 mg/kg/day. Other agents have a low level of evidence. Ampehtamines (available only in Chile and Puerto Rico), with only one study, and the alpha-agonists (clonidine and guanfacine) have been used based on clinical experience only. Further research is needed, especially head to head studies, comparing these agents with the MPD gold standard in both short and long-term follow-up studies. Any treatment decision should be closely monitored in order to make efficacy accurate in clinical response and to provide security for the young patient. While a child is using psychopharmacological treatment, it is important to monitor weight and size monthly. The main modifications to the former version of the Multimodal Treatment Algorithm for Latin American Preschool ADHD are: 1. the specific recommendation of psychosocial treatment such as psychoeducation, PMT, PCIT, and behavioral school-based intervention; 2. the recommendation of methylphenidate (available in all Latin American countries) as first pharmacological agent, followed by atomoxetine or amphetamines, and, in last instance, to consider the use of clonidine, and; 3. psychosocial treatment continuation is recommended for the maintenance jointly with the medication showing the best response.
Conclusions: There are two main pillars for the adequate treatment of preschool ADHD. On the one hand, there are psychosocial interventions such as psychoeducation, PMT, PCIT and behavioral school-based interventions; on the other hand, pharmacological treatment, especially with methylphenidate. Other pharmacological agents have a lack of scientific evidence. As the Multimodal Treatment Algorithm for Latin American Preschoolers with ADHD group, we recommend to start with the psychosocial treatment intervention, and then to follow the pharmacological options. New proposals should be developed according to the special needs and contexts of Latin America.


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