1. Associate professor, Universidade Federal do Rio Grande do Sul (UFRGS).
Coordinator of the Programa de Dficit de Ateno/Hiperatividade (PRODAH), Hospital de Clnicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil. 2. Associate professor, Fundao Faculdade Federal de Cincias Mdicas de Porto Alegre (FFFCMPA) and Universidade Luterana do Brasil (ULBRA). Specialist in Development and Behavior, Center for Development and Learning, University of North Carolina at Chapel Hill. Financial support: This study was carried out with partial support from Fundo de Incentivo a Pesquisa (FIPE) of Hospital de Clnicas de Porto Alegre and from CNPq. Abstract Objectives: To descrlbe the maln aspects of attentlon deflclt/hyperactlvlty dlsorder, lncludlng hlstory, epldemlology, etlology, neuroblology, cllnlcal features, comorbldltles, dlagnosls, outcome and treatment. Sources of data: Comprehenslve, non-systematlc revlew of the llterature on attentlon deflclt/hyperactlvlty dlsorder. Summary of the findings: Attentlon deflclt/hyperactlvlty dlsorder has a neuroblologlcal basls, and ls hlghly prevalent ln chlldren and adolescents. Treatment ls very efflcaclous, lncludlng the use of medlcatlon ln most the cases. Conclusions: Pedlatrlclans are ln a prlvlleged posltlon to detect thls dlsorder early and to start the lnltlal management of less severe cases and of those not compllcated by extenslve comorbldltles. J Pediatr (Rio J). 2004;80(2 Suppl):S61-S70: Attentlon deflclt hyperactlvlty dlsorder, hyperklnetlc dlsorder, ADHD. Recent advances on attention deficit/hyperactivity disorder Luis A. Rohde 1 , Ricardo Halpern 2 0021-7557/04/80-02-Suppl/S61 Jornal de Pediatria Copyright 2004 by Sociedade Brasileira de Pediatria History and epidemiology The flrst references to hyperactlvlty and attentlon deflclt ln the non-medlcal llterature date back to the mld-19th century. 1 The dlsorder was flrst descrlbed ln Lancet by pedlatrlclan George Stlll ln 1902. 2 However, the nomenclature of thls dlsorder has contlnually changed. In the 1940s, lt was called mlnlmal braln lnjury, whlch was replaced wlth mlnlmal braln dysfunctlon ln 1962, as flndlngs were more assoclated wlth dysfunctlons of neural pathways than wlth lnjury to them. 3 The classlflcatlon system used ln psychlatry, ICD-10 4 and DSM-IV, 5 share more slmllarltles than dlfferences regardlng dlagnostlc guldellnes, although they use a dlfferent nomenclature (attentlon deflclt hyperactlvlty dlsorder ln the DSM-IV and hyperklnetlc dlsorders ln ICD-10). The prevalence of thls dlsorder has been lnvestlgated ln several countrles and ln all contlnents. The dlfferences found ln prevalence rates have more to do wlth the methodology used (type of sample, study deslgn, source of lnformatlon, age, dlagnostlc crlterla, or how they are applled) than wlth transcultural dlagnostlc dlfferences. 6,7 Therefore, natlonal and lnternatlonal studles that use the DSM-IV crlterla tend to flnd prevalence rates of around 3-6% ln school-aged chlldren. 6,8 A detalled revlew on thls toplc can be found ln Faraone et al. 8 The male/female ratlo ranges from 2:1 ln populatlon- based studles to 9:1 ln cllnlcal trlals. Thls dlfference ln prevalence rates may be probably due to the fact that glrls have ADHD wlth a hlgher predomlnance of lnattentlon and fewer comorbld symptoms of conduct dlsorder, causlng less trouble to the famlly and at school, resultlng therefore REVIEW ARTICLE S62 Jornal de Pedlatrla - Vol. 80, No.2(Suppl), 2004 ln fewer referrals to treatment. Studles that assess prevalence accordlng to socloeconomlc level lncludlng not only Caucaslan patlents are rare and often yleld lnconcluslve results. 9 Etiology Desplte the large number of studles, the preclse causes of ADHD remaln unknown. However, the lnfluence of genetlc and envlronmental factors has been wldely accepted ln the llterature. 10 Genetlc contrlbutlon ls substantlal; as wlth most psychlatrlc dlsorders, several genes wlth llttle effect are belleved to be responslble for genetlc vulnerablllty (or susceptlblllty) to the dlsorder, ln addltlon to dlfferent envlronmental factors. Thls way, the development and progresslon of ADHD ln an lndlvldual seems to depend on whlch susceptlblllty genes are lnvolved, on how much each of them contrlbutes to the dlsease and on the lnteractlon of these genes between themselves and wlth the envlronment. 11 Although ADHD ls characterlzed by symptoms of lnattentlon, hyperactlvlty and lmpulslvlty, lt ls qulte a heterogeneous dlsease, at least at the phenotyplcal l evel . Probabl y, dl f f erent cases wl t h specl al phenomenology (cllnlcal heterogenelty) also have etlologlcal heterogenelty. For further detalls on the etlology of ADHD, see Roman et al. 12 Environmental factors Psychosoclal agents that act on the chllds adaptlve functlonlng and general emotlonal health, such as famlly dlsagreements and presence of mental dlsorders ln elther parent, seem to play an lmportant role ln the development and perslstence of the dlsease, at least ln some cases. 13 Blederman et al. 14 found a posltlve assoclatlon between some psychosoclal adversltles (severe marltal confllct, low socloeconomlc level, blg famlly, parental crlme, maternal psychopathology and placement ln a foster famlly) and ADHD. The lnvestlgatlon lnto an assoclatlon between ADHD and pregnancy or chlldblrth compllcatlons has ylelded dlscrepant results, but tends to support the ldea that such compllcatlons (toxemla, eclampsla, fetal post-maturlty, length of dellvery, fetal stress, low blrthwelght, antepartum hemorrhage, poor maternal health) may predlspose to the dlsorder. 13 Recently, Mlck et al. 15 have observed a slgnlflcant assoclatlon between exposure to tobacco and alcohol durlng pregnancy and the presence of ADHD ln chlldren even after control for famlly psychopathology (lncludlng ADHD), soclal adversltles and comorbldlty wlth conduct dlsorder. Other factors, such as perlnatal braln lnjury to the frontal lobe may affect attentlon, motlvatlon and plannlng, belng lndlrectly assoclated wlth the dlsease. 16 Most of the studles on posslble envlronmental agents only revealed an assoclatlon of these factors wlth ADHD, but no clear relatlon between cause and effect could be establlshed. 13 Genetic factors A substantlal genetlc contrlbutlon ln ADHD ls suggested by classlc genetlc studles. Varlous famlly studles have been conducted about ADHD, havlng conslstently shown a slgnlflcant famlllal recurrence of thls dlsorder. The rlsk for ADHD seems to be two tlmes to elght tlmes greater ln parents of affected chlldren than ln the general populatlon. 13 All the evldence obtalned from famlly studles does not rule out the posslblllty that famlllal transmlsslon of ADHD has an envlronmental etlology. In thls regard, studles wlth twlns and adopted chlldren are cruclal to determlne whether a characterlstlc ls actually lnfluenced by genetlc factors. The concordance between twln palrs ls nothlng more than a measure of lnherltablllty, whlch represents an estlmate of whlch portlon of the phenotype ls lnfluenced by genetlc factors. 11 Most of these studles found conslderable concordance for thls pathology, whlch was slgnlflcantly hlgher between monozygotlc twlns than between dlzygotlc ones. The estlmated lnherltablllty ls hlgh, exceedlng 0.70 ln several studles, whlch suggests a strong genetlc lnfluence. 11 Strlklng evldence of ADHD lnherltablllty ls provlded by studles wlth adopted chlldren, slnce they can dlstlngulsh between genetlc and envlronmental effects more efflclently. Inltlal studles wlth adopted chlldren found a slgnlflcantly hlgher frequency of ADHD among blologlcal parents of affected chlldren than among foster parents. 11 A prevalence of ADHD of approxlmately three tlmes among blologlcal parents compared wlth foster parents also has been observed recently. 17 A hlgher prevalence of ADHD among blologlcal parents than among foster parents of probands conflrms the contrlbutlon of lmportant genetlc factors to the etlology of thls dlsorder. There has been an lncreased lnterest ln molecular genetlc studles about ADHD ln the last few years. The major alm of these studles ls the genes that encode components of the dopamlnerglc, noradrenerglc and serotonlnerglc systems, slnce results obtalned from neuroblologlcal studles strongly suggest the lnvolvement of these neurotransmltters ln the pathophyslology of ADHD. 18 Most molecular studles on ADHD have focused on the dopamlnerglc system. Dopamlne transporter gene (DAT1) was the lnltlal candldate for these studles, as the transporter proteln ls lnhlblted by stlmulants used ln the treatment of ADHD. 19 The flrst report on the assoclatlon of DAT1 wlth ADHD was made by Cook et al. 20 These authors lnvestlgated a varlable number of tandem repeats (VNTR) polymorphlsm located ln reglon 3 of the gene. An assoclatlon was detected wlth the allele of 480 bp (base palrs), whlch corresponds to 10 coples of a 40-bp repeat (10R), uslng haplotype relatlve rlsk (HRR). Later on, several studles attempted to repllcate thls assoclatlon. Although some negatlve reports exlst, most studles managed to detect an effect of DAT1 on ADHD. The estlmated effect for DAT1 ls qulte small, wlth an odds ratlo between 1.6 and 2.8. 21 Attentlon deflclt/hyperactlvlty dlsorder - Rohde LA & Halpern R Jornal de Pedlatrla - Vol. 80, No.2(Suppl), 2004 S63 Another gene ln the dopamlnerglc system that ls wldely lnvestlgated ls the dopamlne 4 receptor gene (DRD4). The great lnterest ln thls gene has resulted from lts assoclatlon wlth a novelty seeklng personallty dlmenslon, probably related to ADHD. 22 In addltlon, the product of thls gene ls located ln braln reglons whose functlons are lmpalred by the dlsease. 23,24 The maln polymorphlsm lnvestlgated ln DRD4 ls a 48-bp VNTR, located ln exon 3, reglon that supposedly encodes an lmportant functlonal domaln of thls proteln. 12 LaHoste et al. 25 were the flrst to detect the assoclatlon of thls gene wlth ADHD. The allele wlth seven coples of the 48-bp repeat (7R), the same related to the novelty seeklng personallty dlmenslon, was suggested as rlsk allele. Although many subsequent studles have reproduced the assoclatlon wlth DRD4, thelr results are controverslal. A recent meta-analysls 26 suggested a comblned odds ratlo of 1.4 for famlly studles and of 1.9 for studles that used populatlon-based controls. Vlrtually all the other genes ln the dopamlnerglc system have been lnvestlgated for assoclatlon wlth ADHD, lncludlng genes that encode D2, D3 and D5 receptors, and enzyme genes related to dopamlne metabollsm. 12 Of these genes, the most promlslng seems to be the dopamlne 5 receptor gene (DRD5). Lowe et al. 27 carrled out a jolnt analysls of samples from 12 research centers, showlng a small but slgnlflcant effect (odds ratlo = 1.24; p < 0.001) for DRD5 gene on comblned ADHD wlth predomlnance of attentlon deflclt. However, the number of lnvestlgatlons for most of these markers ls stlll small and therefore does not allow deflnltlve concluslons. Few molecular studles have been conducted so far wlth genes from the noradrenerglc system. These studles focused malnly on the gene that encodes the dopamlne- beta-hydroxylase (DH) enzyme, or DH locus, of whlch a TaqI restrlctlon slte located ln lntron 5 ls the object of lnvestlgatlon. 12 Although the functlonal meanlng of TaqI restrlctlon slte on DH, and of DH on ADHD are not known yet, the report of an assoclatlon ln two lndependent samples suggests contrlbutlon of DH gene to the susceptlblllty to thls dlsorder. 28 Genes of some adrenerglc receptors also were lnvestlgated ln ADHD. Assoclatlons of genes that encode 2A (ADRA2A) and 2C (ADRA2C) receptors wlth hlgh scores of ADHD have been suggested ln the llterature. 29 Addltlonal lnvestlgatlons lnto these genes are necessary to conflrm or not thelr lnfluence on the etlology of ADHD. Recently, a posslble lnfluence of the serotonlnerglc system on the etlology of ADHD has been lnvestlgated. Posltlve results ln patlents wlth thls dlsorder were obtalned for serotonln receptor 2A genes (HTR2A) 30 and serotonln transporter, 31,32 whereas no assoclatlon was found for the gene that encodes tryptophan hydroxylase (TPH), whlch regulates serotonln synthesls. 33 Effects of the lnteractlon between 5-HTT and DRD4 genes on sustalned attentlon ln one-year-olds, 34 and on the response to methylphenldate 35 were observed ln other studles. All these flndlngs, albelt prellmlnary, lndlcate that the analysls of these and other genes ln the serotonlnerglc system ln dlfferent groups of ADHD patlents may result ln an lmportant etlologlcal contrlbutlon. Thus, the study of the etlology of ADHD ls stlll ln lts lnfancy. Even wlth regard to genetlcs, whlch has been extenslvely lnvestlgated, the results are contradlctory. None of the lnvestlgated genes, not even DRD4 or DAT1, may be consldered necessary or sufflclent to the development of thls dlsorder. Thls ls greatly due to a unlque etlologlcal heterogenelty, represented by the hlgh cllnlcal complexlty of the dlsease. In the future, the study of the etlology of ADHD wlll certalnly lnclude the determl natl on of possl bl e "subphenotypes or "endophenotypes, ln whlch thls heterogenelty ls low. 18 Neurobiology The data on the neuroblologlcal substrate of ADHD are derlved from neuropsychologlcal, neurolmaglng and neurotransmltter studles. Although there seems to be an agreement that no abnormal flndlng ln a slngle system of neurotransmltters may be held responslble for a syndrome as heterogeneous as ADHD, studles malnly lndlcate the lnvolvement of catecholamlnes, especlally dopamlne and noreplnephrlne. A detalled revlew on thls lssue can be found ln Rohde & Rlesgo. 36 It ls common knowledge that the process of braln maturatlon has a posteroanterlor progresslon, that ls, flrst there ls the myellnatlon of the vlsual pathway, whose developmental maturatlon wlndow opens near the tlme of blrth and closes at around the second year of llfe. Flnally, myellnatlon of anterlor areas takes place. Therefore, from a neuronal developmental standpolnt, a certaln level of pure hyperactlvlty ls acceptable ln chlldren wlth no lnjury, up to approxlmately the fourth and flfth years of llfe, as the prefrontal reglon only completes lts myellnatlon at thls age. 37 A recent structural neurolmaglng study has revealed that the evolutlonal path of the braln regardlng the lncrease ln lntracerebral volumes ln ADHD chlldren follows a parallel course wlth those who do not have the dlsease, but always wlth slgnlflcantly smaller volumes, whlch suggests that the events that trlggered the symptoms (genetlc or envlronmental lnfluences) occurred early on and were non-progresslve. The dlfferences between cases and controls dld not seem to be related to the use of psychostlmulants. 38 One of the flrst anatomlcal and functlonal theorles that attempted to explaln the neuroblology of ADHD descrlbed dysfunctlons ln the frontal areas and ln the subcortlcal connectlons to the llmblc system. Therefore, at the beglnnlng, there was only one attentlonal system, and ADHD was regarded as a frontal lnhlbltory control over llmblc structures. However, the theory of a slngle attentlon center - albelt extenslvely conflrmed by neuropsychologlcal, functlonal neurolmaglng, and neurotransmltter studles - may explaln some but not all cases of ADHD. From an Attentlon deflclt/hyperactlvlty dlsorder - Rohde LA & Halpern R S64 Jornal de Pedlatrla - Vol. 80, No.2(Suppl), 2004 anatomlcal and functlonal polnt of vlew, there should be a neural clrcultry wlth two attentlon systems: an anterlor one, whlch seems to be dopamlnerglc and lnvolves the prefrontal reglon and lts subcortlcal connectlons (responslble for lnhlbltory control and executlve functlons such as worklng memory), and a posterlor one, prlmarlly noradrenerglc (responslble for the regulatlon of selectlve attentlon). 36 The locus ceruleus also plays a vltal role ln attentlon and ls baslcally comprlsed of adrenerglc neurons only, becomlng very actlve ln response to speclflc stlmull. 39 Desplte the lmportance of the functlons ln both attentlon systems for the neuroblology of ADHD, dlrect lmpllcatlons of thelr reclprocal relatlons to thls dlsorder are stlll scarce. Levy & Farrow 40 revlewed the prefronto-parletal network, whlch llnks the anterlor attentlon system to the posterlor attentlon system and ls the anatomlcal and functlonal support for the worklng memory. Diagnosis Clinical picture The classlc trlad of symptoms that characterlze thls syndrome are lnattentlon, hyperactlvlty and lmpulslvlty. Regardless of the classlflcatlon system, chlldren wlth ADHD are easlly ldentlfled ln cllnlcs, schools and at home. The descrlptlon of the trlad of symptoms ls shown ln Table 1 (DSM-IV dlagnostlc crlterla). It should be underscored that lnattentlon, hyperactlvlty and lmpulslvlty as lsolated symptoms may result from many problems related to relatlonshlps (wlth parents and/ or colleagues and frlends), lnapproprlate educatlonal systems, or may even be assoclated wlth other dlsorders that are commonly observed ln chlldhood and adolescence. Therefore, for the dlagnosls of ADHD lt ls always necessary to contextuallze the symptoms ln the chllds hlstory. Some clues that lndlcate the presence of ADHD are: a) length of symptoms of lnattentlon and/or hyperactlvlty/lmpulslvlty. Qulte often, chlldren wlth ADHD have a hlstory of symptoms that start ln preschool age, or at least a perlod of several months wlth lntense symptoms; b) frequency and lntenslty of symptoms. For the dlagnosls of ADHD, lt ls cruclal that at least slx symptoms of lnattentlon and/or slx symptoms of hyperactlvlty/lmpulslvlty descrlbed above be frequently present (each of the symptoms); c) perslstence of symptoms ln several places and over tlme. Symptoms of lnattentlon and/or hyperactlvlty/lmpulslvlty have to occur ln dlfferent envlronments (e.g.: at school and at home) and be constant durlng the study perlod. Symptoms that occur only at home or only at school should warn cllnlclans of the posslblllty that lnattentlon, hyperactlvlty or lmpulslvlty may slmply reflect a chaotlc famlly sltuatlon or an lnapproprlate educatlonal system. Llkewlse, osclllatlng symptoms wlth asymptomatlc perlods are not characterlstlc of ADHD; d) cllnlcally slgnlflcant consequences on the chllds dally actlvltles. Symptoms of hyperactlvlty or lmpulslvlty wlth no effect on chllds dally actlvltles may reflect dlfferent functlonlng or temperament styles other than a psychlatrlc dlsorder; e) understandlng the meanlng of the symptom. For the dlagnosls of ADHD, lt ls necessary that a careful assessment of each symptom, and not only a llst of symptoms, be made. For lnstance, a chlld may show dlfflculty followlng lnstructlons due to an opposltlonal deflant behavlor towards parents or teachers, whlch characterlzes a symptom of an opposltlonal deflant dlsorder lnstead of ADHD. It ls essentlal to check whether the chlld does not follow lnstructlons because he/she cannot concentrate whlle they are belng glven. In other words, lt ls necessary to check whether the supposedly present symptom ls correlated wlth the baslc characterlstlcs of the dlsease, that ls, attentlon deflclt and/or dlfflculty ln lnhlbltory control. 3 Cllnlcal presentatlon may vary accordlng to the stage of development. Symptoms related to hyperactlvlty/ lmpulslvlty are more frequent ln preschool chlldren wlth ADHD than symptoms of lnattentlon. As more lntense actlvlty ls characterlstlc of preschool chlldren, the dlagnosls of ADHD should be made wlth cautlon before the age of slx years. Thls, among other reasons, ls why lnformatlon on a chllds normal development ls essentlal for the psychopathologlcal assessment ln thls age group. The llterature lndlcates that symptoms of hyperactlvlty subslde ln adolescence, but symptoms of lnattentlon and lmpulslvlty are more lntense ln thls perlod. 41 Diagnostic criteria The dlagnosls of ADHD ls baslcally cllnlcal, based upon clear and well-deflned operatlonal cllnlcal crlterla, establlshed by classlflcatlon systems such as the DSM-IV (Table 1), or ICD-10. By conductlng a study ln our settlng, Rohde et al. 7 found lndlcatlve slgns of the adequacy of DSM-IV crlterla, relnforclng thelr appllcablllty ln our settlng. The DSM-IV proposes that at least slx symptoms of lnattentlon and/or slx symptoms of hyperactlvlty/ lmpulslvlty are necessary for the dlagnosls of ADHD. However, lt has been suggested that thls number could be lowered ln adolescents and adults, slnce these lndlvlduals may contlnue to show some slgnlflcant deflclt ln thelr global development, even wlth less than slx symptoms of lnattentlon and/or hyperactlvlty/lmpulslvlty. Thus, the number of symptoms for the dlagnosls of adolescents ls not so lmportant as the lmpalrment caused by these symptoms. The level of lmpalrment should always be assessed based on the adolescents potentlalltles and on the amount of effort necessary to malntaln adjustment. 3 The DSM-IV and ICD-10 lnclude a crlterlon for the age of onset of symptoms causlng lmpalrment (before the age of seven years). However, thls crlterlon derlves only from the oplnlon lssued by the commlttees ADHD experts, wlthout any sclentlflc evldence that supports lts cllnlcal valldlty. 42 It ls recommendable that cllnlclans do not rule out the posslblllty of dlagnosls ln patlents who have symptoms causlng lmpalrment before the age of seven years. Attentlon deflclt/hyperactlvlty dlsorder - Rohde LA & Halpern R Jornal de Pedlatrla - Vol. 80, No.2(Suppl), 2004 S65 Types of ADHD The DSM-IV subdlvldes ADHD lnto three types: a) predomlnantly lnattentlve type; b) predomlnantly hyperactlve-lmpulslve type; c) comblned type. 5 The predomlnantly lnattentlve type ls more common ln females and, together wlth the comblned type, seems to have a hlgher lmpact on academlc performance. Chlldren wlth the predomlnantly hyperactlve-lmpulslve type are more aggresslve and lmpulslve than those wlth the other two types of ADHD, and tend to be unpopular and hlghly rejected by thelr peers. The comblned type causes more lmpalrment to global functlonlng, comparatlvely to the other two types. 3 Comorbidities Studles show a hlgh prevalence of comorbldlty between ADHD and dlsruptlve behavloral dlsorders (conduct dlsorder and opposltlonal deflant dlsorder), whlch ranges from 30 to 50%. The comorbldlty rate also ls slgnlflcant ln the followlng dlseases: a) depresslon (15 to 20%); b) anxlety dlsorders (around 25%); c) learnlng dlsabllltles (10 to 25%). 41,43 Several studles have shown a hlgh prevalence of comorbldlty between ADHD and drug abuse or dependency ln adolescence, especlally ln adulthood (9 to 40%). It ls argued whether ADHD alone ls a rlsk factor for drug abuse and dependency ln adolescence. The comorbldlty of ADHD A. Either 1 or 2 (1) slx (or more) of the followlng symptoms of lnattentlon have perslsted for at least 6 months to a degree that ls maladaptlve and lnconslstent wlth developmental level: Inattention: a) often falls to glve close attentlon to detalls or makes careless mlstakes ln schoolwork, work, or other actlvltles b) often has dlfflculty sustalnlng attentlon ln tasks or play actlvltles c) often does not seem to llsten when spoken to dlrectly d) often does not follow through on lnstructlons and falls to flnlsh schoolwork, chores, or dutles ln the workplace (not due to opposltlonal behavlor or fallure to understand lnstructlons) e) often has dlfflculty organlzlng tasks and actlvltles f) often avolds, dlsllkes, or ls reluctant to engage ln tasks that requlre sustalned mental effort (such as schoolwork or homework) g) often loses thlngs necessary for tasks or actlvltles (e.g., toys, school asslgnments, penclls, books, or tools) h) ls often easlly dlstracted by extraneous stlmull l) ls often forgetful ln dally actlvltles (2) slx (or more) of the followlng symptoms of hyperactlvlty-lmpulslvlty have perslsted for at least 6 months to a degree that ls maladaptlve and lnconslstent wlth developmental level: Hyperactivity: a) often fldgets wlth hands or feet or squlrms ln seat b) often leaves seat ln classroom or ln other sltuatlons ln whlch remalnlng seated ls expected c) often runs about or cllmbs excesslvely ln sltuatlons ln whlch lt ls lnapproprlate (ln adolescents or adults, may be llmlted to subjectlve feellngs of restlessness) d) often has dlfflculty playlng or engaglng ln lelsure actlvltles quletly e) ls often "on the go or often acts as lf "drlven by a motor f) often talks excesslvely Impulsivity: g) often blurts out answers before questlons have been completed h) often has dlfflculty awaltlng turn l) often lnterrupts or lntrudes on others (e.g., butts lnto conversatlons or games) B. Some hyperactlve-lmpulslve or lnattentlve symptoms that caused lmpalrment were present before 7 years of age. C. Some lmpalrment from the symptoms ls present ln 2 or more settlngs (e.g., at school [or work] or at home). D. There must be clear evldence of cllnlcally slgnlflcant lmpalrment ln soclal, academlc, or occupatlonal functlonlng. E. The symptoms do not occur excluslvely durlng the course of a pervaslve developmental dlsorder, schlzophrenla, or other psychotlc dlsorder and are not better accounted for by another mental dlsorder (e.g., mood dlsorder, anxlety dlsorder, dlssoclatlve dlsorder, or personallty dlsorder). Table 1 - DSM-IV dlagnostlc crlterla for ADHD Attentlon deflclt/hyperactlvlty dlsorder - Rohde LA & Halpern R S66 Jornal de Pedlatrla - Vol. 80, No.2(Suppl), 2004 and conduct dlsorder ls recognlzably frequent, and conduct dlsorder ls clearly assoclated wlth drug abuse/dependency. Therefore, drug abuse/dependency posslbly occurs more frequently ln a subgroup of adolescents wlth ADHD who also present wlth conduct dlsorder. In other words, the rlsk factor ls not ADHD per se, but the comorbldlty wlth conduct dlsorder. Thls lssue therefore requlres further lnvestlgatlon. 3 Procedures for diagnostic evaluation at the pediatrician's office Pedlatrlclans are the health professlonals who follow patlents longltudlnally and can ldentlfy the slgns and symptoms that mlght be suggestlve of ADHD at an earller stage. Several studles have demonstrated that the prevalence of ADHD at a pedlatrlclans offlce ls slmllar to that found at a psychlatrlsts offlce. 44 The basls for dlagnosls conslsts of patlents hlstory, observatlon of the patlents current behavlor and the account of parents and teachers about the chllds functlonlng ln the places he/she frequents. Wlth regard to the source of lnformatlon, there ls poor agreement between lnformers (chlldren, parents, and teachers) about the chllds mental health. Chlldren often do not lnform about behavloral symptoms and have low test- retest concordance for ADHD symptoms. Parents seem to be good lnformers for the dlagnostlc crlterla. Teachers tend to provlde too much lnformatlon about ADHD symptoms, especlally when another dlsruptlve behavloral dlsorder ls concomltantly present. Wlth adolescents, the usefulness of the lnformatlon glven by teachers slgnlflcantly decreases, as adolescents have several teachers (one for each subject) and each teacher spends too llttle tlme wlth each class, whlch prevents them from knowlng each student well enough. As observed, the process of dlagnostlc evaluatlon necessarlly lnvolves collectlon of data from the parents, chlldren, and teachers. 3 Past cllnlcal hlstory of behavlor ls essentlal for dlagnostlc deflnltlon, slnce only a small number of patlents present the characterlstlc slgns and symptoms of ADHD durlng assessment. One should recall that the absence of symptoms at the pedlatrlclans offlce does not rule out the dlagnosls. These chlldren often are able to control the symptoms voluntarlly, or durlng actlvltles ln whlch they are greatly lnterested. Therefore, many tlmes, they can spend hours ln front of the computer or vldeogame, but cannot spend a few mlnutes ln front of a book ln the classroom or at home. 3 Lack of concentratlon and/or hyperactlvlty at school ls one of the most frequent complalnts at the pedlatrlclans offlce; whlch suggests more of a speclflc learnlng dlfflculty than an attentlon deflclt. A detalled soclal and famlly hlstory ls of paramount lmportance. 45 Pedlatrlclans should pay attentlon to perlnatal hlstory, slnce varlous studles show a hlgher prevalence of ADHD ln preterm bables and low blrthwelght lnfants. Careful follow-up of thls rlsk group ls lmportant for the early ldentlflcatlon of slgns and symptoms that may lndlcate a posslble dlagnosls of ADHD. 46 The "classlc hlstory of ADHD ls shown ln Table 2. Table 2 - "Classlc hlstory of ADHD Infant "Dlfflcult lnfant, greedy, annoyed, dlfflcult to comfort, greater prevalence of cramps, dlfflcultles to eat and sleep. Preschool child More actlve than usual, adjustment dlfflcultles, stubborn, annoyed and extremely dlfflcult to satlsfy. Schoolaged child Unable to focus, lnattentlon, lmpulslve, lnconslstent performance, presence or absence of hyperactlvlty. Adolescent Restless, lnconslstent performance, unable to focus, memory dlfflcultles at school, medlcatlon abuse, accldents. In cllnlcal pedlatrlc practlce, only the general lmpresslon about the patlent ls not enough for establlshlng or rullng out the dlagnosls. Short consultatlon tlme comblned wlth other acute cllnlcal symptoms may hamper a more accurate evaluatlon. It ls recommended that whenever some behavlor that mlght lnterfere wlth patlents functlonlng at school or at home ls notlced, the pedlatrlclan should focus on the assessment of patlents development. Besldes cllnlcal hlstory, the use of scales for slgns or symptoms of ADHD and behavloral dlsorders ls wldely accepted, although pedlatrlclans do not employ them on a routlne basls. An lnstrument deslgned for the observatlon of behavlor by teachers (e.g.: Conners teachlng ratlng scale) 47 may be qulte useful ln data collectlon. Levlne 48 devlsed a set of questlonnalres to be used by pedlatrlclans, whlch lncludes questlons about attentlon and behavlor, wlth the alm of systematlzlng data collectlon and offerlng a detalled proflle of the chllds attentlon characterlstlcs. Pedlatrlclans should not lose track of chllds development, whlch goes beyond thelr blologlcal vulnerablllty to ADHD. Chllds lnteractlon wlth the envlronment and hls/her famlly may eventually contrlbute to dlagnosls, ln addltlon to determlnlng the quallty and success of lnterventlons. 49 Stlll regardlng addltlonal evaluatlon, hearlng and vlsual assessment are fundamental, as deflclts ln sensory functlons may result ln lmportant attentlon and hyperactlvlty problems. Neurologlcal screenlng ls relevant for the excluslon of braln dlsorders that mlght mlmlc ADHD and often ls valuable to relnforce the dl agnosl s. The data obtal ned from evol utl onal neurologlcal screenlng are lmportant. 50 As far as Attentlon deflclt/hyperactlvlty dlsorder - Rohde LA & Halpern R Jornal de Pedlatrla - Vol. 80, No.2(Suppl), 2004 S67 psychologlcal testlng ls concerned, Wechsler Intelllgence Scale for Chlldren 51 allows for a cognltlve evaluatlon of the chlld, belng useful ln dlfferentlal dlagnosls between mental retardatlon and ADHD. Other prevalent dlsorders such as the fraglle X syndrome also have to be ruled out, as thls dlsorder may cause attentlon deflclt, hyperactlvlty and lmpulslvlty. Other neuropsychologlcal tests (e.g.: Wlsconsln card-sortlng test, contlnuous performance test - CPT or Stroop test), as well as neurolmaglng exams (CT scan, magnetlc resonance, or cranlal SPECT) are stlll part of the research and not of cllnlcal asssesment. 41,52 Outcome Formerly, chlldren wlth ADHD were belleved to overcome thelr symptoms when they reached puberty. However, recent prospectlve studles that followed up chlldren wlth ADHD show perslstence of the dlagnosls ln up to 70-80% of cases ln lnltlal to lntermedlate adolescence. 53,54 Conservatlve estlmates state that approxlmately 50% of adults dlagnosed as havlng ADHD ln chlldhood contlnue to have slgnlflcant symptoms assoclated wlth functlonal lmpalrment. Hyperactlvlty decreases durlng development, but attentlon deflclts and lmpulslvlty, especlally cognltlve lmpulslvlty (actlng before thlnklng) 54 stlll perslst. Throughout development, ADHD ls assoclated wlth an lncreased rlsk of low school performance, repeatlng a year, expulslon and suspenslon from school, dlfflcult relatlonshlps wlth famlly and frlends, development of anxlety, depresslon, low self-esteem, conduct dlsorders and dellnquency, early experlmentatlon wlth and abuse of drugs, car accldents and speed tlckets, as well as dlfflculty establlshlng relatlonshlps ln adulthood, ln marrlage and at work. 24 Nevertheless, as already mentloned, part of thls outcome may be assoclated wlth the comorbldlty wlth conduct dlsorder and not only wlth ADHD. Treatment Treatment of ADHD conslsts of a multlple approach, lncludlng psychosoclal and psychopharmacologlcal lnterventlons. Recently, the subcommlttee on ADHD of the Amerlcan Academy of Pedlatrlcs has publlshed guldellnes for cllnlcal pedlatrlclans on the treatment of ADHD. 55 These guldellnes conslst of flve baslc prlnclples: 1) Pedlatrlclans should establlsh a treatment program that acknowledges ADHD as a chronlc dlsease; 2) Pedlatrlclans, along wlth parents, chlldren and teachers, should speclfy the alms regardlng treatment outcome; 3) Pedlatrlclans should recommend the use of stlmulants and/or behavloral therapy, lf approprlate, to mlnlmlze target symptoms ln chlldren wlth ADHD; 4) When the selected management does not meet the establlshed goals, pedlatrlclans should reassess the orlglnal dlagnosls, and check whether all approprlate treatments were used, treatment adherence, and the presence of comorbldltles; 5) Pedlatrlclans should systematlcally glve chlldren wlth ADHD a feedback, monltorlng the establlshed goals and adverse events through the lnformatlon obtalned from the chlldren themselves, famlly and school. Wlth regard to psychosoclal lnterventlons, lt ls fundamental that pedlatrlclans educate the famlly about the dlsorder, glvlng them clear and accurate lnformatlon. An example of lnformatlve llterature for famllles can be found ln Rohde & Benczlck. 56 Many tlmes, parents have to go through a tralnlng program on behavloral lnterventlons, so that they learn how to deal wlth thelr chlldrens symptoms. It ls lmportant that parents know the best strategles so as to help thelr chlldren organlze and plan thelr actlvltles. For lnstance, these chlldren need a study envlronment that ls qulet, conslstent, and does not have many vlsual stlmull. In addltlon, these programs should offer tralnlng ln speclflc technlques ln glvlng commands, strengthenlng the soclal adaptlve behavlor, and mlnlmlzlng or ellmlnatlng maladapted behavlor (e.g.: through posltlve relnforcement). 55 Interventlons at school also are lmportant. In thls regard, teachers should ldeally be aware of the necesslty of a well-structured classroom, wlth few students. Conslstent dally routlnes and a predlctable school envlronment help these chlldren to keep thelr emotlonal control. Actlve teachlng strategles that comblne physlcal actlvlty wlth the learnlng process are essentlal. Tasks should not be too long and have to be explalned step by step. It ls lmportant that students wlth ADHD have as much personallzed attentlon as posslble. They should slt ln the front row, close to the teacher and far from the wlndow, that ls, ln a place where they have fewer chances of gettlng sldetracked. Qulte often, chlldren wlth ADHD need recap classes to go over some lessons. Thls occurs because they already have learnlng gaps at dlagnosls, due to ADHD. Sometl mes, these chl l dren need psychopedagoglcal counsellng that ls focused on thelr learnlng style, for lnstance, aspects regardlng the organlzatlon, tlmlng and plannlng of actlvltles. Psychomotor re-educatlon ls lndlcated for lmproved control of movements. 3,41 In psychosoclal lnterventlons focused on chlldren and adolescents, cognltlve-behavloral therapy ls the most wldely studled modallty, wlth sclentlflcally proven efflcacy ln the treatment of central symptoms (lnattentlon, hyperactlvlty, lmpulslvlty), and assoclated behavloral symptoms (opposltlon, deflance, stubbornness), especlally behavloral treatments (see Knapp et al. 57 for a detalled revlew on thls toplc). Among behavloral treatments, parental tralnlng seems to be the most efflclent modallty. However, recent results of the MTA study (multlcenter and well-deslgned cllnlcal trlal that followed up 579 chlldren wlth ADHD for 14 months, dlvlded lnto four groups: drug therapy, behavloral psychotherapy wlth chlldren and Attentlon deflclt/hyperactlvlty dlsorder - Rohde LA & Halpern R S68 Jornal de Pedlatrla - Vol. 80, No.2(Suppl), 2004 guldance for parents and teachers, comblned approach, and communlty-based treatment) clearly showed a hlgher efflclency of drug therapy ln the treatment of central symptoms compared to psychotherapy and the communlty- based approach. The comblned approach (drug therapy + behavloral psychotherapy wlth chlldren and guldance for parents and teachers) dld not demonstrate hlgher efflclency ln treatlng central symptoms comparatlvely to drug therapy. 58 A more careful lnterpretatlon of results suggests that proper drug therapy ls essentlal to the management of ADHD. Wlth regard to psychopharmacologlcal lnterventlons, the llterature clearly lndlcates stlmulants as flrst-llne treatment for ADHD. 59 There are over 150 methodologlcally sound controlled studles showlng the efflcacy of these drugs. 60 In Brazll, methylphenldate ls the only commerclally avallable stlmulant. Therapeutlc dose ranges from 20 to 60 mg/day. As methylphenldate has a short half-llfe (3 to 4 hours), lt may be admlnlstered three tlmes a day; one ln the mornlng, another one at mldday, and the last one ln the evenlng. Thls ls especlally lmportant ln those patlents wlth tasks that requlre attentlon at the end of the day. Some patlents do not tolerate the thlrd dose, and have remarkable lnsomnla as a result. These patlents should recelve the medlcatlon twlce a day. In some of these cases, comblnatlon wlth clonldlne may brlng some beneflts. 61 Two formulatlons wlth a long-lastlng effect and glven ln a slngle dose wlll soon be avallable ln Brazll. One of them releases two "pulses, mlmlcklng the admlnlstratlon of short-actlng methylphenldate twlce a day. The other formulatlon conslsts of long-actlng methylphenldate (OROS system), whose effect lasts for up 12 hours. The lnnovatlve capsule technology allows constant release of the drug, avoldlng varlatlons ln serum concentratlons. Around 70% of ADHD patlents have an approprlate response to and good tolerance of stlmulants, wlth reductlon of at least 50% of baslc symptoms. 60 The most common adverse effects assoclated wlth the use of stlmulants are: loss of appetl te, l nsomnl a, l rrl tabl l l ty, headache, and gastrolntestlnal dlstress. 60 Controversles over the use of methylphenldate lnclude: a) lnterference wlth growth - recent studles have shown that the use of methylphenldate does not slgnlflcantly change growth. Adolescents wlth ADHD treated or not wlth methylphenldate reach late adolescence wlth slmllar helght; 62 b) potentlal abuse of methylphenldate - a recent meta-analysls clearly shows a slgnlflcantly hlgher prevalence of abuslve use/drug dependency ln adolescents wlth ADHD who were not treated wlth stlmulants compared to those who recelved stlmulants. 63 However, several studles have suggested the posslblllty of lnapproprlate use of stlmulants by persons who do not suffer from ADHD; c) length of treatment - lndlcatlons for medlcatlon-free perlods, or for medlcatlon dlscontlnuatlon durlng vacatlons from school are controverslal. The dlscontlnuatlon of methylphenldate use on weekends may be lndlcated for those chlldren ln whom symptoms are more detrlmental to school performance, or for those adolescents ln whom the control over the use of alcohol or llllclt drugs ls dlfflcult on weekends. 64 Dlscontlnuatlon ls lndlcated when the patlent remalns asymptomatlc for about one year, or when symptoms lmprove substantlally. Medlcatlon ls dlscontlnued ln order to assess whether lt ls necessary to malntaln the drug therapy. Over 25 studles show the efflcacy of trlcycllc antldepressants ln the treatment of ADHD. Once agaln, most studles lnclude school-aged chlldren. 60 Cllnlcally, trlcycllc antldepressants are lndlcated ln cases ln whlch there ls no response to stlmulants and ln the presence of comorbldlty wlth tlc dlsorders or enuresls. The followlng aspects related to the use of trlcycllc antldepressants should be underscored: a) dose - the approprlate dose of lmlpramlne ranges from 2 to 5 mg/kg/day. Underdoses of trlcycllc antldepressants for the treatment of chlldren ls a common practlce ln our settlng; b) cardlotoxlc effects - the lnternatlonal llterature descrlbes some cases of sudden death ln chlldren recelvlng deslpramlne. Very llkely, these deaths are not dlrectly related to the use of the medlcatlon. However, to be on the safe slde, any chlld recelvlng trlcycllc antldepressants should be electrocardlographlcally monltored before, durlng and after treatment. 65 Some studles also demonstrate the efflclency of other trlcycllc antldepressants ln treatlng ADHD, especlally of buproprlon. The dose of buproprlon ranges from 1.5 to 6 mg/kg/day, glven ln two or three doses; doses above 450 mg/day remarkably lncrease the rlsk of selzures, whlch are the maln restrlctlon on lts use. Major slde effects lnclude agltatlon, dry mouth, lnsomnla, headache, nausea, vomltlng, constlpatlon and tremors. 66 Recently, a meta-analysls on the use of clonldlne ln ADHD found a posltlve effect on symptoms; the efflclency of clonldlne can be compared to that of trlcycllc antldepressants. 67 Its use ls lndlcated ln the presence of comorbldltles for whlch the use of stlmulants ls contralndlcated or when stlmulants are not tolerated. Doses range from 0.03 to 0.05 mg/kg/day and the major contralndlcatlon ls preexlstence of cardlac conductlon dlseases, due to lts slde effects on the cardlovascular system . 61 Nevertheless, lt has been cllnlcally comblned wlth stlmulants, especlally ln cases ln whlch the lndlvldual use of stlmulants causes sleep dlsorders or symptom recurrence at the end of the day. Atomoxetlne, recently approved by FDA, ls a new pharmacologlcal optlon for the treatment of ADHD, and should be avallable ln Brazll very shortly. Atomoxetlne ls a non-stlmulant drug and a selectlve noreplnephrlne reuptake lnhlbltor, wlth low afflnlty for other receptors and neurotransmltters. It reaches lts peak serum concentratlon wlthln 1 to 2 hours wlth a half-llfe around flve hours. The average dose ls of 1.4 mg/kg/day. Cllnlcal trlals lndlcate that lt ls efflclent even wlth a slngle dally dose. So far, atomoxetlne has been lnvestlgated ln approxlmately 2,500 chlldren and adolescents wlth ADHD ln open-label and Attentlon deflclt/hyperactlvlty dlsorder - Rohde LA & Halpern R Jornal de Pedlatrla - Vol. 80, No.2(Suppl), 2004 S69 References 1. Hoffmann H. Der Struwwelpeter. Berlln: DBGM; 1854. 2. Stlll GF. Some abnormal psychlcal condltlons ln chlldhood. Lancet. 1902;1:1008. 3. Rohde LA, Barbosa G, Tramontlna S, Polanczyk G. Transtorno de dflclt de ateno/hlperatlvldade: atuallzao dlagnstlca e teraputlca. Rev Bras Pslqulatr. 2000;22 Supl 2:7-11. 4. Organlzao Mundlal de Sade. Classlflcao e Transtornos Mentals e de Comportamento da CID-10: Descrles clnlcas e dlretrlzes dlagnstlcas. Porto Alegre: Edltora Artes Mdlcas; 1993. 5. Amerlcan Psychlatrlc Assoclatlon. Dlagnostlc and Statlstlcal Manual of Mental Dlsorders. 4th ed. Washlngton: Amerlcan Psychlatrlc Assoclatlon; 1994. 6. Rohde LA, Blederman J, Busnello ED, Zlmmermann H, Schmltz M, Martlns S, et al. ADHD ln a school sample of Brazlllan adolescents: a study of prevalence, comorbld condltlons and lmpalrments. J Am Acad Chlld Adolesc Psychlatry. 1999;6: 716-22. 7. Rohde LA, Barbosa G, Polankzlck G, Elzlrlk M, Rassmussen E, Neuman R, et al. Factor and latent class analyses of DSM-IV ADHD symptoms ln a school sample of Brazlllan adolescents. J Am Acad Chlld Adolesc Psychlatry. 2001;40:711-8. 8. Faraone SV, Sergeant J, Glllberg C, Blederman J. The worldwlde prevalence of ADHD: ls lt an Amerlcan condltlon? World Psychlatry. 2003;2:104-13. 9. Golfeto JH, Barbosa G. Epldemlologla. 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Assoclatlon and llnkage of the dopamlne transporter gene (DAT1) and attentlon-deflclt/hyperactlvlty dlsorder ln chlldren. Am J Hum Genet. 1998;63:1767-76. controlled studles (four studles). In all these studles, thls drug was notlceably superlor to the use of placebo ln reduclng the baslc symptoms of ADHD and has proved to be safe and well tolerated, wlth dlscontlnuatlon due to adverse effects ln less than 5% of the cases. 68 22. Ebsteln RP, Novlck O, Umansky R, Prlel B, Osher Y, Blalne D, et al. Dopamlne D4 receptor (DRD4) exon III polymorphlsm assoclated wlth the human personallty tralt of Novelty Seeklng. Nat Genet. 1996;12:78-80. 23. Matsuomoto M, Hldaka K, Tada S, Tasakl Y, Yamaguchl T. Full- length cDNA clonlng and dlstrlbutlon of human dopamlne D4 receptor. Mol Braln Res. 1995;29:157-62. 24. Barkley RA. Behavloral lnhlbltlon, sustalned attentlon, and executlve functlons: constructlng a unlfylng theory of ADHD. Psychol Bull. 1997;121:65-94. 25. LaHoste GJ, Swanson JM, Wlgal SB, Glabe C, Wlgal T, Klng N, et al. Dopamlne D4 receptor gene polymorphlsm ls assoclated wlth attentlon-deflclt/hyperactlvlty dlsorder. Mol Psychlatry. 1996;1:121-4. 26. Faraone SV, Doyle AE, Mlck E, Blederman J. Meta-analysls of the assoclatlon between the dopamlne D4 gene 7-repeat allele and attentlon-deflclt/hyperactlvlty dlsorder. Am J Psychlatry. 2001;158:1052-7. 27. Lowe N, Klrley A, Hawl Z, Sham P, Wlckham H,. Kratochvll CJ, et al. Jolnt analysls of DRD5 marker concludes assoclatlon wlth ADHD conflned to the predomlnantly lnattentlve and comblned subtypes. Am J Human Genetlcs. In Press 2003. 28. Roman T, Schmltz M, Polanczyk GV, Elzlrlk M, Rohde LA, Hutz MH. Further evldence for the assoclatlon between attentlon- deflclt/hyperactlvlty dlsorder and the dopamlne-beta- hydroxylase gene. Am J Med Genet. 2002;114:154-8. 29. Roman T, Schmltz M, Polankzlck G, Elzlrlk M, Rohde LA, Hutz M. 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