Palacios CL, Zavaleta RP, Patiño DR, Abadi A, Diaz JD, Taddey N, Garrido G, Rubio E, Grañana N, Muñoz C, Sosa ML
Language: Spanish
References: 92
Page: 31-44
PDF size: 161.87 Kb.
ABSTRACT
Introduction: The prevalence of the attention deficit hyperactivity disorder (ADHD) in childhood is 3% to 5%; apparently, its expression during adolescence is not lower. Around 65% of the children diagnosed with ADHD continue meeting criteria for the diagnosis through adolescence and the rest appear to maintain some symptoms that cause dysfunction in at least two areas of their life. Many factors may play a role in adolescents who met ADHD criteria in the past and continue to manifest dysfunction, although they do not meet diagnostic criteria. At this age group, one factor may be the decrease in sensibility in different diagnostic approaches. When the diagnosis of ADHD is established during childhood, the task of the mental health professional is to continue with the treatment as much as it is needed. However, some adolescents who attend first time evaluation do not have a previous diagnosis and ADHD symptoms may be subtler during puberty. In sharp contrast with ADHD diagnosed during childhood, when it is diagnosed in adolescence, often times it presents itself with more complications due to the deterioration it generates in the individual’s psychosocial development, especially when it has not been adequately treated in the past.
In Latin America, studies have been carried out that include adolescent population with ADHD, albeit most of them include children. In Brazil, for example, a study including 1013 students 12-14 years old was carried out, it showed that the prevalence of ADHD was around 6%, and that it came about with a high comorbidity with behavioral disruptive disorders (48%). In this study, youths with ADHD showed a higher probability of having lower academic performance, (e.g. history of more repetitions of school grade, suspensions and expulsions of schools), in comparison with the group without ADHD. With regards to gender, a meta-analysis including 25 studies between 1996-2006 reported a prevalence of mental illness in adolescent population (n=14,639). The estimated prevalence of ADHD among women was reported to be higher than in men (18% vs. 12%), contrary to what was been reported in childhood. Another complication of ADHD among adolescent population is that there is a higher risk of suffering comorbid psychiatric disorders with ADHD, such as oppositional defiant disorder, conduct disorder, affective disorders, and substances use disorders, which increase the dysfunction and complicate the treatment. It has been reported that adolescents with ADHD and comorbid internalizing disorders (e.g. depression, anxiety) have better compliance and treatment outcomes than those with externalizing disorders. Adolescents with ADHD have a quality of life similar to adolescent patients with a chronic physical illnesses. Hence, it is extremely important to recognize and to give an appropriate treatment that diminishes the impact this disorder has on overall function. With this clinical picture in mind, ADHD has become a problem of public health in Latin American countries, thus the inclusion of medical doctors of first and second level of attention, with regards to education, diagnosis and treatment of this disorder and its possible complications, is of the utmost importance.
The practice guidelines for the treatment of mental health problems in children and adolescents integrate the pharmacological treatment with psychosocial (such as psychotherapy, parent management training including psicoeducation). The multicentric randomized studies carried out in the United States have identified specific advantages for the multimodal treatment compared to the medication alone, including improvement not only in symptoms but in family functioning as well. At the moment, there is more evidence showing that the psychopharmacological treatments for adolescents with ADHD, the stimulants mainly and also atomoxetine, are effective and efficient, making them the first line of intervention. Even though pharmacological treatment is the pillar for the treatment of this disorder, the addition of psychosocial interventions at all stages in life, directed to the parents, teachers and the affected individual, is strongly recommended given the need for a multimodal treatment of ADHD and to better assist the way the patient’s environment shapes this disorder. Although psychosocial treatments for parents and children with ADHD are routinely recommended and there is sufficient evidence of its efficiency, its use in adolescents with ADHD has not been evaluated in a consistent way.
The most important study providing evidence of the utility of the psychosocial interventions for the treatment of ADHD is the multimodal study of treatment in children with ADHD (MTA), which included 579 children, who were followed-up through adolescence. This study evaluated four treatment modalities assigned in a random manner during 14 months of active intervention: 1. pharmacological treatment alone, 2. intensive behavioral therapy alone, 3. a combination of the two previous treatments and 4. community treatment: the commonest treatment. The results showed that all the groups had a decrease in ADHD symptoms at the 14-month follow-up, the effect was larger for the medication and the combined treatment without differences between both groups. The combination of medication and psychosocial treatment had more benefits than the medication alone group in children with ADHD and a comorbid disorder, mainly with anxiety disorders. It also showed improvements in the use of social tools and changes in negative and ineffective rearing styles.
The implications that psychosocial factors have in the etiology and prognosis of patients with ADHD lead us to think that it is necessary to include certain psychosocial interventions in the integral treatment of this illness. There are several psychosocial interventions that have been used in the treatment of ADHD, but only a few of them have evidence of their effectiveness in adolescents with ADHD. The objective of psychosocial interventions is to provide parents the tools to handle the behavior of their children and to help the latter to acquire academic and social abilities in order to improve their functioning in these areas. At the present time three main models of psychosocial intervention are considered: a) Family interventions. b) School interventions and c) Individual interventions. Psychoeducational programs support children and adolescents with ADHD providing parental advice, giving information about the treatment, supporting parents, as well as promoting the communication among parents, teachers, and the health team. The objectives of psicoeducation are: 1. To improve the knowledge and understanding of ADHD and its implications in daily life. 2. To offer adjustment possibilities to the environment according to the patient’s level functioning. 3. To offer a guide that facilitates and promotes a positive parent-child interaction and pattern of behavior. 4. To offer an introduction on how behavioral modifications can be applied to the handling of behavioral problems. 5. To guide and inform on the social, educational, and health supports available. Although the implementation of psychoeducational programs does not require a formal training on the part of the person giving them, it is advisable for the instructor to be highly familiarized with psychosocial treatments based on the principles of behavioral management.
Despite reports, consensus, and treatment algorithms put forward by highly qualified scientific groups in other parts of the world in an effort to guide, suggest, and/or standardize ADHD treatment, Latin America needs a treatment proposal in accordance with our scientific and contextual limitations.
The Multimodal Treatment Algorithm for Latin American Adolescents with ADHD is a new proposal for the treatment of such patients. This proposal is understood as a new management option for adolescent patients with ADHD. It seems important to state here that the final treatment should be individualized and comprehensive, taking into account the patient’s clinical characteristics and the treating physician’s empiric experience. This treatment algorithm allows for the integration and the flexible and reasoned use of different treatment stages, such as psychopharmacological and psychosocial interventions.
Methodology: To bring about this treatment algorithm, especially for the psychopharmacological tree, we carried out a publication search of the studies with the best evidence level according to evidence-based medicine. This search was conducted mainly through OVID and PUBMED; key words were: deficit of attention and hyperactivity, the name of the medication, trial, clinical and controlled. An age limit was also set that included patients from the ages of 0 to 18 years. Special attention was paid to studies with a double-blind, randomized and controlled with placebo (or active substance) design. Abstracts from these articles were read. Those that did not include an adolescent population (older than 13 years) or that did not specify the patients’ ages were discarded. At the end, a total of 264 studies for metilfenidate, 43 for atomoxetine and three for bupropion, six for modafinil, two for venlafaxine, 4 for clonidine, two studies for guanfacine, one of reboxetine, one for imipramine, and one for nortriptiline were identified and used to elaborate this treatment algorithm.
Results: Stage 0. Marks the beginning starting off with the complete clinical interview using multiple informants including the adolescent, obtaining the initial psychometric measurements, and determining the level of severity. Once the diagnosis has been established, information is given to the parents and patient regarding ADHD, its nature, treatment, and initial strategies for behavior management.
Stage 1. consists of methylphenidate monotherapy, preferably a prolonged release formulation; in the case of partial or null response, after a two week treatment with the therapeutic dose, a methylphenidate formulation change is suggested. The suggested therapeutic dose is 0.3mg/kg/day up to 1.2 mg/kg/day.
Stage 1A. Consists of an extensive psychoeducation directed to parents and adolescent. The response to this strategy should be evaluated 4-6 weeks after the psychosocial intervention has been applied.
Stage 2. Recommends the re-evaluation of the initial diagnosis and atomoxetine monotherapy. The initial dose should be 0.5 mg/ kg/day and titrated from one to three weeks to a dose of 1.2-1.8mg/ kg/day in a once-or twice-daily total dosage. Response to atomoxetine should be evaluated after four weeks of treatment at the target doses.
Stage 2A. In the case where a partial or null response has been obtained, the first suggestion is to evaluate compliance to the initial psychosocial intervention, family functioning, and the presence of additional psychopathology in any family member. Begin parent behavior training.
Stage 3. Recommends using combined methylphenidate and atomoxetine. In this stage, before using a combined treatment strategy, a re-evaluation of the initial diagnosis and the investigation of possible side effects that might be jeopardizing compliance should be done. Once the combined strategy has been implemented, response to treatment should be evaluated two weeks after the desired dose of the stimulant has been reached.
Stage 3A. Suggests the evaluation of compliance to the psychosocial interventions used up to this point. Family functioning should be properly evaluated. Once the latter has been achieved, school interventions with teachers are recommended. Once the school intervention has been implemented, response should be evaluated four to six weeks later.
Stage 4. Involves the use of either modafinil or bupropion at a therapeutic dosage (modafinil 100-400mg/day or bupropion 150-300mg/day); the evaluation of the response should be carried out by week four of treatment. In the case the medication is not tolerated or if there is a partial or null response to the treatment after four weeks, a change to the medication not used at the initial part of this stage is suggested.
Stage 4A. Suggests starting some form of cognitive behavioral either individual or group therapy (CBT). Furthermore, an evaluation of compliance to previous psychosocial strategies used prior to this stage, a re-evaluation of family functioning, and the recommendation of psychiatric treatment for any family member with a mental health problem should be done. An evaluation of treatment response to CBT should be carried out by week four or six.
Stage 5. A re-evaluation of the diagnosis and, in specific cases, the use of interventions with limited empirical evidence may be considered at this stage.
Conclusion: This algorithm includes pharmacological and psychosocial interventions to treat rationally ADHD in adolescents.
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