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ADHD Tratament Și Intervenție
ADHD Tratament Și Intervenție
Adresa de coresponden:
Univ.Dimitrie Cantemir Tg. Mure
mail: stanciu_camelia74@yahoo.com
Tel. 0740-526.123
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Correspondence adress:
Dimitrie Cantemir University, Tg. Mures
mail: stanciu_camelia74@yahoo.com
Tel. 0740-526.123
Revista de Neurologie i Psihiatrie a Copilului i Adolescentului din Romnia 2012 vol. 15 nr. 2
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Referat general
Low, K., 2009, Wondering If You Have Adult ADD?, About.com Guide, April 11
Revista de Neurologie i Psihiatrie a Copilului i Adolescentului din Romnia 2012 vol. 15 nr. 2
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Revista de Neurologie i Psihiatrie a Copilului i Adolescentului din Romnia 2012 vol. 15 nr. 2
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Wender, P.,1996, ADHD in Adults, Psychiatric Times, vol. 13. no. 7, p. 7-9
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Referat general
nidate (Ritalin), pemoline (Cyclert), l-deprenyl (selegiline), bupropion (wellbutrin), levodopa, dl-phenylalanine i l-tyrosine, iar n cazul lotului de control
tratament placebo. Autorul a constatat c aprox.
60% dintre pacienii crora li se administreaz medicaie stimulant manifest progrese semnificative,
comparativ cu cei numai 10% din lotul de control,
care au beneficiat de tratament placebo. Rezultatele
celor dou loturi au fost evaluate cu ajutorul Global
Assesement of Functioning (DSM-IV). Dintre toate
substanele administrate efecte majore au fost evideniate n urma administrrii de methylphenidate, pemoline i a inhibitorilor MAO.
Un tratament complet n cazul adulilor cu ADHD
implic informarea acestor persoane asupra tulburrii,
precum i prezentarea matricei terapeutice n care se explic avantajele i dezavantajele administrrii medicaiei. Printre modificrile pe care pacienii le pot resimi n
urma administrrii medicaiei, Wender enumer:
reducerea gradului de agitaie motric; pacienii
devin capabili s se relaxeze, s stea aezai
pentru mai mult vreme la birou sau n timpul
vizionrii unui film;
capacitatea de concentrare se mbuntete
semnificativ; crete atenia pacienilor la
conversaiile conjugale i, implicit, reducerea
conflictelor maritale;
se reduc momentele de plictiseal, starea
psihic fiind descris ca stabil;
pacienii devin mai puin irascibili, izbucnirile
de furie se reduc ca frecven i intensitate,
pn la dispariia total;
se mbuntete capacitatea de organizare (la
coal, pe plan profesional, acas);
devin capabili s nfrunte problemele de via,
devenind mai robuti n faa situaiilor dificile;
se mbuntete capacitatea de ascultare
a conversaiilor altor persoane, devin mai
tolerani n trafic, obinnd o cretere a controlului impulsurilor n situaii sociale.
Tratamentul adulilor cu ADHD include adesea
substane stimulante. Acestea au ca reacii adverse creterea tensiunii arteriale i a pulsului, ceea ce
ar putea duce la accidente vasculare i la atacuri de
cord. nainte de iniierea oricrui tratament, adulii cu
ADHD ar trebui s beneficieze de o examinare medical complet5) (Austin et al, 2007).
5
Austin, M., Reiss, N., Burgdorf, L., 2007, Adult ADHD Treatment Medication, About. com Guide
Revista de Neurologie i Psihiatrie a Copilului i Adolescentului din Romnia 2012 vol. 15 nr. 2
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Revista de Neurologie i Psihiatrie a Copilului i Adolescentului din Romnia 2012 vol. 15 nr. 2
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Referat general
Revista de Neurologie i Psihiatrie a Copilului i Adolescentului din Romnia 2012 vol. 15 nr. 2
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sindrom au artat c nu este tulburat doar metabolismul dopaminei, ci i al altor neuromediatori serotonina i noradrenalina.
1.3.2. Studii genetice:
Descoperirile recente din genetic, n special de
genetic molecular au demonstrat implicarea mai
multor gene n geneza ADHD. Indubitabil, ADHD
este o tulburare genetic poligenic, n care nu numai o gen este afectat. La aceast concluzie s-a
ajuns de altfel i pe cale empiric cercetnd familiile
copiilor cu ADHD; cci copiii care provin din familii afectate sunt de 5-7 ori mai predispui s prezinte
afeciunea dect cei care provin din familii neafectate,
iar copiii care au un printe cu ADHD au anse de
50% s prezinte sindromul. n plus, studiile pe gemeni
au demonstrat c 80% din diferenele n ceea ce privete atenia, hiperactivitatea i impulsivitatea ntre
persoanele care au ADHD i cele care nu au pot fi
explicate prin factori genetici. Factorii care sunt legai de ADHD, dar nu au un substrat genetic sunt:
naterea prematur, consumul de alcool i igri n
timpul sarcinii, expunerea la radiaii n mica copilrie
i prezena unor tulburri ale creierului care implic
lobul prefrontal.(Comings et al, 2000; Wender, 2000;
Barkley, 2006 b; Arnsten et al, 2009).
Studiile de psihopatologie n familiile cu cazuri de
hiperactivitate cu deficit de atenie, studiile de adopie
i studiile pe gemeni au sugerat prezena unei contribuii genetice n etiologia acestei tulburri. Evidenele primare au evideniat i faptul c la taii copiilor
hiperactivi exist o inciden crescut de alcoolism,
sociopatie i un istoric al copilriei ncrcat de dificulti de nvare i tulburri de comportament. De
asemenea, s-a evideniat corelaia dintre simptomele
ADHD i consumul timpuriu de alcool la copiii provenii din familii alcoolice.
Sindromul deficitului de atenie i hiperactivitate (ADHD) se consider a fi puternic influenat de
factorii genetici, deoarece pe lng multitudinea
studiilor asupra gemenilor care indic faptul c imaturitatea global constituie o parte a efectelor genetice
ale ADHD la biei i fete, s-a constatat i prezena unei multitudini de factori parentali care intervin
(Wender, 1987 i 2000; Murphy and Barkley, 1996;
Lensch, 2000; Searight and Rottnek, 2000; Schmidt
et al, 2002; Barkley, 2006 b i 2008; Low, 2009): genetici (transmiterea afeciunii) i educaionali (modele
de comportament, aspecte ale ataamentului, capacitatea de a oferi recompense i de a respecta reguli de
ctre prinii cu ADHD sau prinii normali care au
copii cu ADHD).
1.3.3. Importana factorilor de mediu:
Capacitatea de a susine un nivel eficient de concentrare intelectual i afectiv deriv, cel puin n
parte, din abilitatea prinilor de a ntri urmrirea
unor scopuri cu sens. S-a constatat c acei copii care
provin din familii haotice nu reuesc s-i dezvolte
aceast capacitate. Atenia unui copil poate fi fragmentat de un mediu extrem de distractibil sau de
anxietate (n special legat de performana la sarcinile
colare dificile). De asemenea, conflictele psihologice
interne pot determina orientarea ateniei spre interior
i disturbane ale mecanismelor atenionale.
Chiar dac aceast idee nu este acceptat astzi,
cu mai muli ani n urm se considera c exist o relaie ntre hiperactivitate i diet. Acestei teorii i se
conferise un grad destul de mare de credibilitate n
urma unor relatri ale prinilor, care descriau reaciile
comportamentale ale copiilor lor hiperactivi n urma
ingerrii unor alimente. Cercetrile curente nu au
identificat existena nici unui suport tiinific pentru
aceast teorie.
1.3.4. Contextul psihologic:
Instabilitatea psihomotorie caracteristic sindromului ADHD poate face parte dintr-o reacie la o
situaie traumatizant. Cu ct copilul este mai mic,
cu att modul n care el exprim o dificultate motric sau o tensiune psihic trece mai uor prin corp,
determinnd o tensiune reacional. Copilul de 2-3
ani i chiar mai mare prezint o instabilitate natural,
obinuit, manifestat prin atenie labil i motricitate
exploziv, legat adesea de multiplicarea experienelor i descoperirilor. Anturajul ns nu accept cu
uurin aceast conduit. n faa atitudinilor intolerante ale mediului, copilul cu instabilitate motric i
poate exacerba simptomele i manifestrile. Deci, se
pune problema gradului de toleran al anturajului,
n special familial, fa de simptomele psihomotorii.
Acest grad este foarte redus n familiile n care unul
sau chiar ambii prini au ADHD. Intervenia psihologic - educativ, formativ sau terapeutic, ct i
consilierea privind modificarea stilului parental (dac
e cazul) este deseori necesar i benefic, att pentru
adultul cu ADHD, ct i pentru copil sau familie
n ntregul su (Barkley et al, 2006 a; Murphy and
Barkley, 1996).
1.3.5. Prognostic:
Sindromul ADHD constituie o problem important de sntate public. Prevalena acestuia variaz
ntre 4% i 19%, depinznd de criteriile utilizate (Tay-
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R
ussell Searight, T., Burke, Rottnek, F., 1 noiembrie 2000, Adult
ADHD: Evaluation and Treatment in Family Medicine, Family Medicine of St. Louis Residency Program, St. Louis, Missouri, American
Family Physician
Low, K., 2009, Wondering If You Have Adult ADD?, About.com Guide, April 11
Journal of Romanian Child and Adolescent Neurology and Psychiatry 2012 15th vol. no. 2
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If the answer to most questions is yes, and manifested behaviours are quite severe, interfering with
daily activities, it is possible that the person concerned
to show the syndrome. An accurate diagnosis can be
established only by a professional, who can exclude a
number of other syndromes that may have similar manifestations in some stage of their evolution (depression, bipolar disorder, drug addiction, anxiety, phobias).
Before presentation the evaluation mode of the
ADHD in adults, we review the diagnostic criteria
for ADHD according to DSM-IV-TR - valid in a
small proportion of adults with ADHD:
A. Either (1) or (2):
1. Six (or more) of the following symptoms of
lack of attention that persisted for at least six
months, at a level indicating poor adaptation
and inconsistent with the developmental level:
Inattention
a. often they dont pay attention to details or
they make mistakes because of negligence, at
work or other activities;
b. it is often difficult to concentrate on work
tasks or on playing;
c. frequently, does not seem to listen when spoken to;
d. often does not follow the instructions and not
finish their homework, chores or obligations
(not due to an disturbance of opposition or
misunderstanding of instructions);
e. has often difficulties to organize tasks and
activities;
f. often avoids, dislikes or is reluctant to engage
in tasks that require sustained mental effort
(such as school work or homework);
g. often loses the materials necessary for tasks or
activities (eg., toys, homeworks, pencils, books
or tools);
h. his attention is frequently and easily distracted
by external stimulus.
i. he is often forgetful in daily activities.
2. Six (or more) of the following symptoms of
hyperactivity-impulsivity have persisted for at
least six months, to a poor adjustment and inconsistent with developmental level:
Hyperactivity
a. frequently moves his hands or feet or foiete
a wheelchair;
b. often rises from his seat in classroom or in
other situations in which to sit;
c. often runs or climbs in situations where it is
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Wender, P.,1996, ADHD in Adults, Psychiatric Times, vol. 13. no. 7, p. 7-9
contributions to
the knowledge of the neurobiological mechanisms underlying the ADHD and its upholding to the adult age.
Thus, it has been demonstrated the involvement
of the preforntal and parietal lobe, the limbic system,
the basal nuclei and the cerebellum in the genesis of
different clinical forms of ADHD- by studies of the
computerize EEG (an increasing amonut of slow theta waves especially in the prefrontal lobe, and in some
cases an increasing amonut of the beta waves), confirmed by the studies on the local cerebral blood flow,
5
Austin, M., Reiss, N., Burgdorf, L., 2007, Adult ADHD Treatment Medication, About. com Guide
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children and those with ADHD. The brain areas often described in the MRI studies as being involved
in determining ADHD, are shown in Figure 2. It can
be observed thereby, that the areas resposable for the
ADHD syptomatology are mainly: the prefrontal
cortex and the striaded area.
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BIBLIOGRAFIE / BIBLIOGRAPHY
1. Arnsten AFR, Berridge CW, McCracken JT. The Neurobiological Basis of Attention Deficit Hyperactivity Disorder, Primary Psychiatry, 2009, 16 (7): 47-54.
2. Austin M, Reiss N, Burgdorf L. Adult ADHD Treatment
Medication, About. com Guide, 2007.
3. Barkley RA, Fischer M, Smallish L, Fletcher K. Young
adult outcome of hyperactive children: adaptive functioning in major life activities. J Am Acad Child Adolesc Psychiatry, 2006, 45: 192-202.
4. Brennan AR, Arnsten AFR. Neuronal Mechanisms Underlying Attention Deficit Hyperactivity Disorder. The Influence of Arousal on Prefrontal Cortical Function, Ann NY
Acad Sci, 2008, 1129: 236245.
5. Carlsson ML. On the role of cortical glutamate in obsessive-compulsive disorder and in the attention-deficit hyperactivity disorder, two phenomenologically antithetical
conditions, Acta Psychiatr Scand, 2000, 102: 401-413.
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15. Taylor E, Dopfner M, Sargeant J, Asherson P, Banaschewski T et al, European clinical guidelines for hyperkinetic disorder first upgrade. Eur Child Adolesc Psychiatry, 2004, 13
(suppl.I): 7-30.
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