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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 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

Language: Spanish
References: 108
Page: 17-29
PDF size: 153.80 Kb.


ABSTRACT

Introduction: The development of algorithms for school age children in the region began during the first Latin American Consensus held in Mexico City, in September 2007. These algorithms included only the pharmacological treatment option. After the second Latin American Consensus, that took place in Mendoza, Argentina, in September of 2008, it was clear we needed to incorporate the psychosocial treatment perspective into the algorithms. In this new algorithm, psychosocial and pharmacological interventions for school age children are included. The aim of this article is to present, in a rational and up-to-date way, the best evidence-based data for the multimodal treatment of ADHD in school age children.
Method: An expert panel of 10 different specialists in psychiatry, child and adolescent psychiatry and neuropediatric from six different countries from the region (Mexico, Argentina, Chile, Venezuela, Brazil and Honduras) was created. Each member panel developed an abstract of the established themes and their manuscripts were contrasted with data-based articles about the psychosocial and pharmacological areas in school age children with ADHD. The final integration of the article was a consensual agreement among the authors.
Results: Psychosocial interventions may be divided in tree areas: 1. Family interventions including psychoeducation and training programs for parents. 2. School Age Children interventions including psychoeducation to teachers and peers, training programs to teachers, and academical assistance. 3. Child training in social skills.
Basic psychoeducation offers primary scientific information about the illness, its symptoms and treatment options to parents and patients. Broad psychoeducation includes information to teachers and offers coping skills to parents, teachers and patients on how to manage the manifestations of ADHD. The general goals of psychoeducation are: 1. To improve the knowledge of ADHD and its every day implications. 2. To offer changes in the natural environment adjusted according to the patient’s functional level. 3. To offer a guide to improve parentchild relationship and to promote positive behavioral conduct patrons. 4. To offer an introduction in how behavioral modifications could be applied into the management of conduct problems. 5. To guide and inform about social, educational, and health resources and facilities. Parents training programs had been highly developed, mainly by the Brown and Barkley’s models. With these programs, parents learn how to identify and manage children’s behavioral problems, to promote positive behaviors, to diminish undesirable conducts, and to improve behavioral interventions without aggression.
Scholl Age Children interventions include psychoeducation to teachers and peers, training programs and academical assistance. The Training programs include reward implementation activities, points achievement working systems, and time-out from the classroom; academical assistance, in turn, should be developed according to patients’ needs.
Child training in social skills aims to modify the patient’s overall social behavior. The most commonly used strategies are summer camp activities developed in five to eight weeks, during this period the patient receive several conduct and social interventions.
Pharmacological interventions may be divided in two areas: stimulant medications and non-stimulant medications. Stimulant medications include methylphenidate and amphetamines. However, the only Latin American country where amphetamines could be found was Chile. Methylphenidate could be found in almost all the other countries of the region. The methylphenidate recommended mean dose is around 0.6 to 1 mg/kg/day, even though the NICE guide lines recommend 2.1 mg/kg/day, not exceeding 90 mg/day.
Non stimulant medications include: atomoxetina, tricycle antidepressants, modafinil, bupropion, and alpha adrenergic agonists. Atomoxetine had shown to be effective in reducing the main ADHD symptoms in school age children; the recommended doses are 1.2 to 1.8 mg/kg/day. In almost all comparisons between methylphenidate and atomoxetine, the former had demonstrated a higher effect size and a higher percentage of symptoms remission. Tricycle antidepressants had been used largely and since a long time ago; the most widely used are imipramine and desipramine. The recommended doses are 1 to 4 mg/kg/day, no exceeding 200 mg/day; electrocardiographic evaluations are needed before and during installation. Modafinil has been not authorized by the Food and Drug Administration in the USA to treat ADHD, but in several countries in Latin America it has been allowed to be used by the different health ministries; the recommended dose is 5.5 mg/day. Bupropion needs to be used carefully as it could diminish the seizure umbral and could also increase tics; the recommended dose is 150 to 300 mg/day. The only alpha adrenergic agonist available in Latin America is clonidine and as with imipramine and desipramine; electrocardiographic evaluations are needed before and during installation, the recommended doses is 3 to 5 mcg/kg/day.
The combined use of medicaments and other pharmacological agents must be considered only with expert supervision.
Decision algorithm: Stage 0: The clinician must base the diagnostic on data obtained from different informants. The use of diagnostic interviews and severity rating scales is highly recommended. The family needs, hopes and believes must be considered in establishing the multimodal treatment. Side effects and biological markers, such as cardiac rate, blood pressure, height and weight, need to be obtained in basal and subsequent visits. Basic psychoeducation needs to be implemented. There is no scientific background on the proposed sequence of combined pharmacological and psychosocial interventions; it was established by consensus among the authors.
Stage 1: Use methylphenidate and evaluate response after two weeks; with partial response, change stimulant or presentation and evaluate response after two more weeks; with a partial response, shift to Stage 1A.
Stage 1A: Continue using stimulant. Begin a broad psychoeducation and evaluate response after four to six weeks; with a partial response, shift to Stage 2.
Stage 2: Use atomoxetine and evaluate response after four weeks; with a partial response, shift to Stage 2A.
Stage 2A. Continue using atomoxetine. Begin a parent training program and evaluate response after four to six weeks; with a partial response, make a diagnosis reevaluation. If ADHD continues, shift to Stage 3.
Stage 3: Use tricycle antidepressants and evaluate response after four weeks; with a partial response, change to modafinil or bupropion and evaluate response after four weeks; with a partial response, change to Stage 3A.
Stage 3A: Continue using the last medication. Begin a school intervention and evaluate response after four to six weeks, with a partial response, shift to Stage 4.
Stage 4: Use alpha adrenergic agonists and evaluate response after four weeks; with a partial response, shift to Stage 4A.
Stage 4A: Continue using alpha adrenergic agonists. Begin child training in social skills and evaluate response in four to six weeks; with a partial response, make a diagnosis reevaluation. If ADHD continues, shift to Stage 5.
Stage 5: Use a combination or other pharmacological agents only with expert supervision.
Conclusions: This algorithm for the treatment of ADHD in school age Latin American children was developed by a group of mental health professionals of the region and includes the most recent advances in pharmacological and psychosocial treatments, all of which are presented in a rational and easy to improve way.


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