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Referat general

Camelia Stanciu Sindromul de adhd la aduli criterii de Referat


diagnostic igeneral
intervenie

SINDROMUL DE ADHD LA ADULI CRITERII DE DIAGNOSTIC


I INTERVENIE.
SYNDROME OF ADHD IN ADULTS - DIAGNOSTIC CRITERIA AND
INTERVENTION.
Camelia Stanciu1, Andrei Cotru2
Rezumat
Acest studiu are ca subiect sindromul de hiperactivitate cu deficit de atenie (ADHD) la adult, avnd la baz teoriile etiologice,
simptomele specifice i criteriile de diagnostic n uz. Importana acestei teme const n faptul c simptomatologia sindromului
ADHD al copilriei, aa cum au artat o serie ntreag de studii care au folosit criterii valide de diagnostic va persista la peste
50% din cazuri la vrsta de adult. Totui, manifestrile specifice deseori se schimb pe durata vieii, iar ca urmare este foarte
posibil ca manifestrile sindromului la adult s fie subdiagnosticate. Deseori sunt afectai att copiii ct i prinii. Adulii cu sau
fr ADHD n calitate de prini ai unui copil cu ADHD au nevoie de intervenie psihologic formativ n vederea abilitrii cu
mijloace educative adecvate fa de proprii lor copii.
Cuvinte cheie: ADHD, criterii de diagnostic la adult, relaia neurobiologie psihologie, intervenie formativ.
Abstract
The subject of this research is the syndrome of attention deficit hyperactivity disorder (ADHD) in adults, based on etiological
theories, specific symptoms and diagnostic criteria in use. The importance of this theme is that childhood ADHD symptoms,
as shown by a number of studies that used valid diagnostic criteria - will last more than 50% of cases in older adults. However,
specific manifestations often change during life, and as following it is very likely that the manifestations of this syndrome are
underdiagnosed in adults. Adults with and without ADHD, as parents of a child with ADHD need psychological formative
intervention, for empowering appropriate educational resources to their own children.
Keywords: ADHD, diagnostic criteria in adult, neurobiology psychology relationship, formative intervention.
1
2

Conf.Dr.Psiholog, Univ.Dimitrie Cantemir Tg. Mure


Asistent univ.drd., Univ.Dimitrie Cantemir Tg. Mure

Adresa de coresponden:
Univ.Dimitrie Cantemir Tg. Mure
mail: stanciu_camelia74@yahoo.com
Tel. 0740-526.123
1
2

Associated Professor Psychologist, Dimitrie Cantemir University, Tg. Mures


Assistant Professor, Dimitrie Cantemir University, Tg. Mures

Correspondence adress:
Dimitrie Cantemir University, Tg. Mures
mail: stanciu_camelia74@yahoo.com
Tel. 0740-526.123

1.1. Delimitri conceptuale


Cercetrile din domeniul neuropsihobiologiei demonstreaz c ADHD reprezint un deficit neurobiologic, cu determinism genetic, care poate fi puternic
influenat educaional1) (Dobrescu, 2010). Adulii cu
ADHD care devin prini reprezint modele negative, iar parentingul este un eec. Ca urmare, este important cunoaterea i diagnosticarea adulilor care
se ocup de copil.
ADHD se manifest prin afectarea funciilor
1

 obrescu, I., (sub red.), 2010, Manual de Psihiatrie a Copilului i Adolescentului,


D
vol. I, Ed. Medica, p. 316

Revista de Neurologie i Psihiatrie a Copilului i Adolescentului din Romnia 2012 vol. 15 nr. 2

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Camelia Stanciu Sindromul de adhd la aduli criterii de diagnostic i intervenie

executive (organizare, planificare, memorie de lucru,


atenie selectiv, flexibilitate), datorat disfunciilor
dopaminergice i noradrenergice din ariile sistemului limbic (amigdala cerebral, girusul cingulat anterior, hipocamp).
ADHD este caracterizat printr-un debut precoce,
nainte de vrsta de 7 ani i printr-o combinaie ntre
hiperactivitate, comportament dezordonat i lips de
concentrare a ateniei, incapacitate de utilizare corect a deprinderilor, nelinite, impulsivitate i un grad
crescut de distractibilitate. Aceste particulariti sunt
pervazive i persistente n timp.
1.2. Evaluare i tratament
Adulii care au pstrat o parte dintre simptomele
ADHD prezente n copilrie sunt de obicei diagnosticai ca manifestnd sindromul n remisie parial.
Evaluarea ADHD la aduli conduce la necesitatea modificrii criteriilor DSM-IV existente, n locul
celor 6 criterii fiind suficient ndeplinirea a 5 dintre
acestea2) (Searight et al, 2000).
Exist un consens n ceea ce privete dezinhibiia
drept caracteristic central a sindromului. Persoanele
sunt incapabile s-i inhibe rspunsurile i manifest
deficite n monitorizarea propriului comportament.
Hiperactivitatea ca trstur comun printre copiii
cu ADHD este mai puin evident n cazul adulilor;
impulsurile spontane observate n cazul copiilor sunt
nlocuite n cazul adulilor de nelinite, dificulti de
relaxare i sentimentul de a fi tot timpul la limit.
Nu exist un singur test care s identifice sindromul i nu exist posibiliti practice de determinare
a indicatorilor genetici sau biologici specifici, care s
conduc spre stabilirea unui diagnostic. Acesta va avea
la baz o evaluare comprehensiv, ce trebuie s includ: examinarea antecedentelor i un examen fizic,
pentru a exclude orice alt potenial surs de manifestare a simptomatologiei, o examinare psihologic i
un interviu cu partenerul de via al adultului, printe
sau prieten apropiat.
Simptomele ADHD difer de la o persoan la
alta, dar potrivit criteriilor Manualului Statistic i
Diagnostic al Tulburrilor Mentale (DSM-IV-TR),
acestea pot include : nelinite, irascibilitate i dificulti de relaxare.
Procesul de diagnosticare al acestui sindrom la
2

 ussell Searight, T., Burke, Rottnek, F., 1 noiembrie 2000, Adult


R
ADHD: Evaluation and Treatment in Family Medicine, Family Medicine of St. Louis Residency Program, St. Louis, Missouri, American
Family Physician

40

Referat general

aduli este mult mai complex, din cauza varietii


afeciunilor care produc o simptomatologie similar. Aceste afeciuni includ: dependena de alcool sau
droguri, depresia i disfuncii ale tiroidei.
Cu toate c recunoaterea simptomelor la aduli
poate fi dificil, odat diagnosticai, acetia au mai multe opiuni pentru tratament. Medicamente stimulante,
precum Ritalin, pot produce posibile efecte secundare
nedorite. Anumite remedii homeopatice au fost catalogate ca fiind extrem de eficiente la unii pacieni (de ex,
Avina Sativa ovz verde i Gingko Biloba).
Multe cercetri susin faptul c medicaia ar trebui
s constituie doar o parte a tratamentului. Abordarea
multimodal pare a fi cea mai optim modalitate de
ameliorare a simptomelor.
Printre simptomele specifice ADHD la aduli se
numr:
ntrzieri constante i uitarea sarcinilor;
anxietate;
lipsa aptitudinilor de organizare;
stim de sine sczut;
dificulti de control a furiei;
impulsivitate
Aceste simptome trebuie s fie persistente cel puin n ultimele 6 luni.
Dac aceste dificulti sunt ignorate, se pot produce tulburri n sfera emoional, social, ocupaional
i academic.
Multe persoane atribuie propriile manifestri luptei lor cu stresul i ritmului rapid al vieii n care triesc,
ns acestea pot fi simptome ale sindromului ADHD
nediagnosticate. n aceast situaie, rspunsurile la urmtoarele ntrebri ne-ar putea ajuta3) (Low, 2009).
Eti distras foarte uor?
Ai dificulti de concentrare?
Tinzi s fii dezorganizat?
n timpul unei conversaii te concentrezi asupra mesajului partenerului?
De obicei uii lucruri (de ex., o ntlnire sau
anumite obligaii)?
Ai dificulti urmrind un proces care are pai
multipli?
Ai dificulti la iniierea sau la finalizarea unui
proiect?
Ai tendina de a amna anumite activiti?
Ai dificulti n stabilirea prioritilor?
Devii repede nerbdtor?
Te simi adesea agitat sau nelinitit?
3

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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Camelia Stanciu Sindromul de adhd la aduli criterii de diagnostic i intervenie

Ai dificulti legate de managementul timpului?


Ai dificulti n gsirea obiectelor acas sau la
serviciu?
Acionezi nainte de a te gndi la consecine?
Vorbeti nainte de a te gndi la impactul pe
care l au vorbele tale asupra celorlali?
Tinzi s ai o mulime de gnduri?
Te plictiseti uor?
Faci greeli atunci cnd lucrezi la un proiect
plictisitor sau dificil?
i asumi frecvent riscuri?
Dac la majoritatea ntrebrilor rspunsul este
da, iar comportamentele manifestate sunt destul de
severe, interfernd cu activitile zilnice, este posibil
ca persoana n cauz s manifeste sindromul. Un diagnostic precis poate fi stabilit doar de ctre un profesionist, care s exclud o serie de alte sindroame ce
pot avea manifestri similare ntr-o anumit etap a
evoluiei lor (depresie, tulburare bipolar, toxicomanii,
anxietate, fobii).
nainte de prezentarea modului de evaluare a
ADHD la aduli trecem n revist criteriile de diagnostic ale ADHD dup DSM-IV-TR valide la o
mic parte dintre adulii cu ADHD:
A. Fie (1) sau (2):
1. ase (sau mai multe) din urmtoarele simptome ale lipsei de atenie care au persistat timp
de cel puin 6 luni, la un nivel care s indice o
adaptare deficitar i incompatibil cu nivelul
de dezvoltare:
Neatenia
a. deseori nu acord atenie detaliilor sau greete din neglijen la teme, la munc sau n alte
activiti;
b. i este adesea dificil s se concentreze la sarcinile de lucru sau la joac;
c. n mod frecvent, pare c nu ascult cnd i se
vorbete;
d. adesea nu urmrete instruciunile i nu i
termin temele, treburile casnice sau obligaiile de serviciu (nu datorit unei tulburri de
opoziie sau nenelegerii instruciunilor);
e. are des dificulti n a-i organiza sarcinile i
activitile;
f. frecvent evit, i displace sau are reineri s se implice n sarcini ce necesit un efort mental susinut (cum ar fi activitile colare sau temele);
g. pierde adeseori materialele necesare unor sarcini sau activiti (de ex., jucrii, teme, creioane, cri sau unelte);

h. atenia i este distras frecvent i foarte uor de


ctre stimuli externi;
i. este adesea uituc n ceea ce privete activitile
cotidiene.
2. ase (sau mai multe) din urmtoarele simptome ale hiperactivitii-impulsivitii care au
persistat timp de cel puin 6 luni, la un nivel de
adaptare deficitar i incompatibil cu nivelul
de dezvoltare:
Hiperactivitatea
a. i mic frecvent minile sau picioarele sau se
foiete pe scaun;
b. se ridic adesea de pe scaun n clas sau n alte
situaii n care trebuie s stea aezat;
c. adeseori alearg sau se car n situaii n care
acest lucru nu este adecvat (la adolesceni i
aduli se poate limita la sentimente subiective
de agitaie);
d. are des dificulti n a se juca sau participa la
activiti recreative n linite;
e. se afl frecvent n continu micare sau se
comport ca i cum ar fi bgat n priz;
f. adesea vorbete excesiv de mult.
Impulsivitatea
a. frecvent i scap rspunsurile nainte ca ntrebrile s fie complet formulate;
b. are des dificulti n a-i atepta rndul;
c. i ntrerupe sau i deranjeaz pe alii n mod
frecvent (de ex., intr n vorb sau n jocuri).
B. Unele simptome ale hiperactivitii-impulsivitii sau ale neateniei ce au dus la probleme
au fost prezente naintea vrstei de 7 ani.
C. Dificultile datorate acestor simptome sunt
prezente n dou sau mai multe mprejurri: la
coal (sau la locul de munc) i acas.
D. Trebuie s existe dovezi clare ale unor deteriorri semnificative n ndeplinirea funciilor
sociale, academice sau ocupaionale.
E. Simptomele nu apar exclusiv n cadrul unei
tulburri pervazive de dezvoltare (PDD), a
schizofreniei sau a oricrei alte psihoze i
nu pot fi asociate unei alte tulburri mentale
(cum ar fi nevroza, anxietatea, disocierea sau o
tulburare de personalitate).
Coduri bazate pe tipul de ADHD:
314.01 Deficitul de atenie nsoit de tulburare hiperkinetic, tipul combinat: dac ambele criterii (A1
i A2) s-au manifestat n ultimele 6 luni.
314.00 Deficitul de atenie nsoit de tulburare hiperkinetic, tipul predominant neatent: dac crietriul A1

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Camelia Stanciu Sindromul de adhd la aduli criterii de diagnostic i intervenie

s-a manifestat n ultimele 6 luni, dar nu i criteriul A2.


314.01 Deficitul de atenie nsoit de tulburare
hiperkinetic, tipul predominant hiperactiv-impulsiv:
dac criteriul A2 s-a manifestat n ultimele 6 luni, dar
nu i criteriul A1.
Not: La persoanele care au n prezent simptome
care se ncadreaz doar parial n criterii (n special adolescenii i adulii) trebuie specificat n remisie
parial.
314.9 Tulburarea cu hiperactivitate i deficit de
atenie fr alt specificaie
Aceast categorie este destinat tulburrilor cu
simptome notabile de neatenie sau hiperactivitateimpulsivitate care nu satisfac criteriile pentru deficitul
de atenie nsoit de tulburare hiperkinetic.
Criteriile Utah (Wender, 1995; 2000) pentru
evaluarea sindromului ADHD la aduli:
Istoric al copilriei consecvent cu ADHD;
Simptomatologie specific
Hiperactivitate i concentrare deficitar
Labilitate afectiv
Impulsivitate
Incapacitate de finalizare a sarcinilor i dezorganizare
Toleran sczut la frustrare
Criteriile Utah includ n componena lor i aspectele emoionale. Episoadele impulsive, caracterizate
prin erupii temperamentale sunt date uitrii foarte
repede de persoana n cauz, dar sunt mai dificil de
uitat de ctre colegii sau membrii familiei sale.
Labilitatea afectiv este caracterizat prin izbucniri scurte, intense i variaz de la euforie la mnie
i disperare.
Alte manifestri ale adulilor cu ADHD includ
afectarea urmtoarelor 5 dimensiuni:
Activitatea i organizarea (se refer la
dificultile resimite de persoan n a-i organiza zilnic sarcinile);
Atenia susinut (include aspecte cum ar fi:
distragerea, visarea cu ochii deschii);
Energia durabil i efortul (stare de somnolen,
grad redus de finalizare a sarcinilor);
Gestionarea interferenelor afective (motivaie
sczut, iritabilitate, toleran sczut la frustrare);
Memoria de lucru i capacitatea de reactualizare a informaiilor (performane sczute).
P. Wender4) (1996) a realizat un amplu studiu asupra a 300 de pacieni cu ADHD, utiliznd n cazul
grupului experimental psihostimulante: methylphe4

Wender, P.,1996, ADHD in Adults, Psychiatric Times, vol. 13. no. 7, p. 7-9

42

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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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Camelia Stanciu Sindromul de adhd la aduli criterii de diagnostic i intervenie

1.3. Etiologie, mecanisme


i intervenie n ADHD:
1.3.1. Baza neurobiologic:
Metodologia modern de investigaie, n special
aa-numita imagistic funcional (fMRI- functional
Magnetic Resonance Imaging, PET Positron Emission Tomography, SPECT single positron emiission
computed tomography, a), dar i investigaiile de neurofiziologie, dintre care electroencefalografia /EEG
cantitativ, potenialele evocate sau MEG (magnetoEEG) a adus contribuii importante la cunoaterea mecanismelor neurobiologice care stau la baza
ADHD i a perpeturii sale la vrsta de adult. Astfel,
s-a demonstrat implicarea lobului prefrontal i parietal, a sistemului limbic, a nucleilor bazali i a cerebelului n geneza diferitelor forme clinice de ADHD fie
prin studii de EEG computerizat (creterea cantitii
undelor lente teta n special la nivelul lobului prefrontal, iar n anumite situaii a undelor beta), confirmate
de studiile asupra fluxului sanghin cerebral local, care
demonstreaz o scdere a acestuia n regiunile prefrontale i la nivelul legturilor dintre aceste regiuni
i sistemul limbic via zona striat, n special la nivelul
nucleilor caudai (Himelstein et al, 200; Brennan and
Arnsten, 2008; Arnsten et al, 2009).
De asemenea, studiile care utilizeaz PET pentru a
evalua metabolismul glucozei cerebrale (vezi figura 1)
au demonstrat scderea acestuia la aduli (Zametkin
et al. 1990), dar i la adolescentele cu ADHD. S-au

constatat diferene ntre fetele i bieii adolesceni,


deocamdat neexplicate, ntre aspectele metabolismului cerebral n ADHD (Ernst et al., 1997; 1998). n
plus, s-au constatat asimetrii funcionale semnificative ale diverselor zone cerebrale, astfel de exemplu, s-a
constatat diminuarea activitii metabolice n regiunea frontal anterioar stng, strns corelat cu severitatea simptomelor ADHD (Zametkin et al., 1990),
fapt care confirm relaia dintre activarea cerebral a
unei anumite regiuni i comportamentul caracteristic
celor cu ADHD.
Studiile bazate doar pe tomografia computerizat
simpl (CT) nu au identificat nici o diferen semnificativ ntre copiii, respectiv adulii normali i cei cu
ADHD, dar s-a putut observa o mai mare atrofie a
creierului la adulii cu ADHD care au avut n plus antecedente de abuz de substane. Acest abuz ns explic
mult mai bine atrofia dect ADHD (Barkley, 2006 b).
Analiza mult mai sensibil a structurilor cerebrale
pe baza MRI i fMRI identific o serie de diferene
n unele zone corticale ntre copiii normali i cei cu
ADHD. Zonele cerebrale adesea descrise n studiile
MRI ca fiind implicate n determinarea ADHD, sunt
indicate n figura 2. Se poate observa astfel, c zonele responsabile de simptomatologia ADHD sunt n
principal: cortexul prefrontal i zona striat.

Figura 2. Emisfera cerebral dreapt indicnd zonele corticale


implicate preponderent n determinarea ADHD (dup Barkley,
2006a i 2006 b)

Figura 1. Analiza activitii cerebrale pe baza PET la ADHD i


la persoanele fr ADHD. (dup.Zametkin et al,1990)
n partea dreapt a figurii se poate observa c persoanele cu
ADHD au o activitate cerebral mai puin intens dect cele fr
aceast tulburare n ceea ce privete controlul activitii. Tratamentul medicamentos urmrete activarea acestor
centri ai controlului.

Hynd et al. (1993) susin c la copiii cu ADHD


regiunea nucleilor caudali din emisfera stng este
mai mic, avnd astfel o configuraie invers dect la
copiii normali. Dac n populaia normal nucleii caudali din emisfera stng sunt mai mari comparativ
cu cei din emisfera dreapt, la copii cu ADHD aceast configuraie nu se respect. Rezultatele lui Hynd
(1993) sunt consistente cu studiile care au identificat
scderea fluxului sangvin local n aceste regiuni. Studii similare, utiliznd MRI cantitativ, indic o regi-

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Camelia Stanciu Sindromul de adhd la aduli criterii de diagnostic i intervenie

une frontal mai mic a emisferei drepte precum i o


mai mic mrime a nucleilor caudali i a globus pallidus la copiii cu ADHD, comparativ cu copii normali
(Castellanos et al, 2002). Aceiai autori au identificat
un volum al cerebelului mai mic la ADHD dect la
normali, fapt ce este consistent cu cercetrile recente
care atribuie cerebelului un rol major n manifestarea
motric a unor aspecte rezultate din activitatea de planificare i a celorlalte funcii executive.
Un aspect particular demonstrat de aceste studii
se refer la mrimea nucleilor caudai, care este mai
mic la copiii cu ADHD dect la cei normali; nu exist ns un consens privitor la care anume parte a nucleilor este mai mic. Hynd i colab. (1993), Ernst et
al (1998),Giedd et al (2001), identific zona stng a
nucleilor caudai ca fiind mai mic; iar Castellanos et
al. (1996 i 2002) identific descrie nuclei caudai mai
atrofici n dreapta. Creierul persoanelor normale prezint o asimetrie constant a regiunii frontale a emisferelor, cea dreapt fiind mai mare fa de cea stng
(Giedd et al., 2001). Acest argument l-a determinat
pe Castellanos s susin c lipsa acestei asimetrii ar
putea media manifestrile specifice pentru ADHD.
Este important de reinut c nici unul dintre studiile de neuroimagistic nu au identificat faptul c persoanele cu ADHD prezint leziuni cerebrale. Aspectele
descrise de aceste studii se refer doar la mrimea unor
zone cerebrale, de cele mai multe ori lipsind asimetria
(fie dintre regiunile frontale, fie dintre nucleii caudai i
globus pallidus) n timp ce aceste asimetrii sunt ntlnite la persoanele normale. Cnd sunt identificate deficite la nivel cerebral, cel mai adesea ele sunt rezultatul
anormalitilor aprute n dezvoltarea acestor regiuni
cerebrale din cauze cel mai probabil de natur genetic.
n cele din urm, genele determin n mare parte dezvoltarea cerebral (Barkley, 2006 a; 2006 b; 2008).
Cercetrile de neurochimie cerebral, dezvoltate exploziv nc din anii 90 au artat c simptomele
ADHD sunt cauzate de o disfuncie neurofiziologic
a creierului. Diverse studii utiliznd PET i SPECT
au confirmat faptul c exist o diferen clar definit
ntre indivizii cu ADHD i cei fr. Mecanismele de
la baza ADHD sunt complexe i sunt n continuare cercetate. S-a constatat c balana chimic a creierului este dezechilibrat i neurotransmitorii, n
special dopamina (dar i noradrenalina, serotonina,
glutamatul) i receptorii lor sunt n cantiti sczute
n anumite regiuni cerebrale, de obicei asimetric, la
cei cu ADHD, nu numai n cortex, ci i n nucleii
subcorticali, sistemul limbic, cerebel i trunchiul ce44

Referat general

rebral. O serie de autori au demonstrat aceste aspecte,


ct i corelarea lor anumite modificri a funciilor psihologice i comportamentale din ADHD (Zametkin,
1990; Murphy and Barkley, 1996; Ernst et al, 1998;
Carlsson et al, 2000; Comings et al, 2000; Himelstein et al, 2000; Roth and Saykin, 2004; Arnsten et al,
2009). Astfel, s-a constatat c, de exemplu, cortexul
prefrontal drept este implicat n editarea comportamentului i rezistena la distractori. Nucleul caudat
i globul palid ajut la stingerea rspunsului automat
pentru a permite o deliberare din partea cortexului i
a coordona input-ul neurologic n variate regiuni ale
cortexului. Rolul exact al vermisului nu este clar, dar
studiile efectuate pn acum sugereaz faptul c intervine n planificare i motivaie. Totui, rolul major
pare a fi deinut de disfuncia cortexului prefrontal,
cci debitul sanghin cerebral este sczut cu 65% la copiii cu ADHD pe durata efortului intelectual fa de
aspectul ntlnit la copiii normali.
Tot n cadrul posibilelor cauze ale tulburrii am
putea aminti un experiment care a demonstrat existena unei legturi ntre abilitatea unei persoane de a
fi atent i nivelul de activitate al creierului. Subiecilor participani la experiment li s-a dat spre memorare o list de cuvinte. S-a utilizat PET i s-a msurat
nivelul de glucoz utilizat de ariile care inhib impulsurile i controleaz atenia. Glucoza este cea mai
important surs de energie a creierului. Cercettorii
au descoperit diferene importante ntre persoanele
cu ADHD i cele fr. La cei cu ADHD s-a constatat un nivel mai sczut al consumului de glucoz,
de unde rezult existena unui nivel de activitate mult
mai redus n unele pri ale creierului, care poate cauza neatenie.
S-a presupus i s-a confirmat c la baza patogenezei sindromului stau tulburrile de activizare a
formaiunii reticulare, care contribuie la coordonarea
nvrii i la capacitatea de meninere a ateniei. Tulburrile funciei de activizare a formaiunii reticulare
sunt legate de insuficiena de noradrenalin. Imposibilitatea unei prelucrri adecvate duce la situaia n
care diferii stimuli vizuali, sonori, emoionali devin
de prisos pentru copil, provocnd nelinite, agitaie i
agresivitate. De altfel, cu ani n urm, dr. Paul Wender6) (Wender, 1996) avansa teoria conform creia
MBD poate avea o origine genetic, fiind produs
de o scdere a funcionrii catecolaminergice. Unele
cercetri biochimice efectuate asupra copiilor cu acest
6

Wender, P., op.cit., p. 11

Revista de Neurologie i Psihiatrie a Copilului i Adolescentului din Romnia 2012 vol. 15 nr. 2

Referat general

Camelia Stanciu Sindromul de adhd la aduli criterii de diagnostic i intervenie

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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45

Camelia Stanciu Syndrome of adhd in adults - diagnostic criteria and intervention

lor, 1994). Prognosticul su este prost, cci la vrsta


adult persoanele cu ADHD prezint un risc crescut
de delicven, criminalitate, abuz de droguri, eec familial i profesional i alte probleme de adaptare social. A fost evideniat faptul c acei copii provenii din
familii cu status economic sczut i bieii, n general
prezint un risc mai mare de a dezvolta acest sindrom.
1.3.6. Mecanisme psihologice utilizate n intervenia psihoterapeutic:
Se pune problema cum anume structura creierului
i anomaliile genetice observate la copiii cu ADHD
sunt legate de caracteristicile comportamentale ale
tulburrii ? Cum se poate interveni psihoterapeutic
la copil pentru prevenirea persistenei la adult a afeciunii ?
Barkley (2006 a; 2006 b; 2008) a concluzionat c
n ADHD deficitul central se refer la inhibiia comportamental i la autocontrol.
Autocontrolul sau capacitatea de inhibiie/amnare
a rspunsului motor iniial la un anumit eveniment
reprezint o fundamentare critic pentru orice fel
de sarcin. Copiii n cretere ctig capacitatea de
a exercita control asupra activitii mentale, asupra
funciilor executive, care i ajut s ignore distractorii,
s-i redenumeasc scopurile i s urmeze paii necesari pentru a le atinge. Pentru a atinge un scop n
munc sau n joc, oamenii trebuie s fie capabili s-i
reaminteasc scopul, s-i stpneasc emoiile i s-i
canalizeze corect motivaia.
Funciile executive care intervin n acest proces
(Roth and Saykin, 2004; Schmidt et al, 2002) pot fi
grupate n patru activiti mentale, a cror exersare
este obligatorie n intervenia psihoterapeutic n
vederea prevenirii perpeturii ADHD de la vrsta de
copil la cea de adult:
Memoria de lucru pstreaz informaii n timpul
executrii unei sarcini, chiar dac stimulul original
*
*

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care a furnizat informaia a disprut. Aceast evocare


este crucial pentru comportamentul direcionat spre
scop; el furnizeaz mijloace de a imita comportamentul complex i nou al altora (toate aceste aspecte sunt
observate la persoanele cu ADHD).
Interiorizarea limbajului este o alt funcie executiv. nainte de vrsta de 6 ani, copiii vorbesc cu sine
cu voce tare, amintindu-i n mod frecvent cum au
realizat o sarcin particular sau ncercnd s rezolve
o problem. Internalizarea, auto-direcionarea vorbirii
le permite s se reflecte pe sine, s urmeze reguli i
instruciuni, s foloseasc auto-chestionarea ca form
de rezolvare a problemei i s dobndeasc abilitatea
de a construi meta-reguli(baza pentru nelegerea
i folosirea regulilor). S-a constatat c internalizarea
auto-direcionrii vorbirii este ntrziat la copiii cu
ADHD.
Controlul emoiilor, motivaiei i strii de arousal
reprezint a treia funcie executiv implicat.
Reconstituirea ultima dintre funciile executive
folosit pentru dobndirea autocontrolului acompaniaz dou procese separate: reprimarea comportamentului observat i combinarea prilor n noi aciuni
care nu sunt nvate din experien. Capacitatea de
reconstituire ofer indivizilor un grad mare de influen, flexibilitate i creativitate; aceasta permite oamenilor s se concentreze asupra unui scop, fr a memora mecanic paii necesari. Acest lucru permite copiilor
s-i direcioneze comportamentul de-a lungul creterii intervalelor prin combinarea comportamentelor
dintr-un lan lung, pentru atingerea scopurilor.

1.1. Conceptual Delimitations


Neuropsihobiological research shows that ADHD
is a neurobiological deficit with genetic determinism,
which can be strongly influenced by education1) (Dobrescu, 2010). Adults with ADHD who become parents are negative patterns and parenting is a failure.
1

 obrescu, I., (sub red.), 2010, Manual de Psihiatrie a Copilului i Adolescentului,


D
vol. I, Ed. Medica, p. 316

46

It is therefore important to know and diagnose adults


dealing with children.
ADHD is manifested by impairing executive functions (organizing, planning, working memory, selective
attention, flexibility), due to dysfunction of dopaminergic and noradrenergic areas of the limbic system (cerebral amygdala, anterior cingulate gyrus, hippocampus).

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Camelia Stanciu Syndrome of adhd in adults - diagnostic criteria and intervention

ADHD is characterized by an early onset, before


the age of 7 and a combination of hyperactivity, disorganized behaviour and poor concentration, inability
to use the correct skills, anxiety, impulsivity and high
level of distractibility. These features are pervasive and
persistent over time.
1.2. Evaluation and Treatment
Adults who have kept some of the symptoms of
ADHD presented in childhood are usually diagnosed
as showing the syndrome in partial remission.
Assessment of ADHD in adults leads to the need
to amend existing DSM-IV criteria, instead of the 6
criteria are sufficient to fulfill five of them2) (Searight
et al, 2000).
There is a consensus regarding disinhibition - as
a central feature of the syndrome. People are unable
to inhibit responses and show deficits in monitoring
their behaviour. Hyperactivity - as a common feature
among children with ADHD is less evident in adults;
spontaneous impulses observed in children, at adults
are replaced by restlessness, difficulty relaxing and feeling of being always borderline.
There is no single test to identify the syndrome
and there is no practical possibility of determining the
specific genetic and biological indicators, leading to a
diagnosis. It will be based on a comprehensive assessment, which must include: examination of background and physical examination, to exclude any other
potential source of manifestation of symptoms, a
psychological examination and an interview with the
adult`s spouse, parent or close friend .
ADHD symptoms differ from person to person,
but corresponding to the criteria in the Diagnostic
Statistical Manual of Mental Disorders (DSM-IVTR), this may include: restlessness, irritability and
difficulty in relaxing.
The diagnosis of this syndrome in adults is much
more complex, because of the variety of conditions
that produce similar symptoms. These conditions include: alcohol or drug addiction, depression and thyroid dysfunction.
Although the recognition of symptoms in adults
can be difficult, once diagnosed, they have more options for treatment. Stimulant medications such as
Ritalin, can cause possible unwanted side effects.
2

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

Certain homeopathic remedies have been classified as


extremely effective in some patients (eg, Avin Sativa green oats and Gingko Biloba).
Many studies argue that the medication should be
only part of the treatment. Multimodal approach seems to be the best way to improve symptoms.
The specific symptoms of ADHD in adults include:
constant delays and forgetting tasks;
anxiety;
lack of organizational skills;
low self-esteem;
difficulty controlling anger;
impulsivity
These symptoms must be persistent at least the last
six months.
Ignoring these difficulties, can cause problems in the
emotional, social, occupational and academic areas.
Many people assign their own symptoms to their
fight with stress and the fast pace of the life they live,
but these can be symptoms of undiagnosed ADHD.
In this situation, answers to the following questions
might help us 3)(Low, 2009).
Are you easily distracted?
Do you have difficulty concentrating?
Do you tend to be disorganized?
During a conversation, do you concentrate on
your partner`s message?
Do you usually forget things (eg., a meeting or
certain obligations)?
Do You have difficulty following a process that
has multiple steps?
Do you have difficulty initiating or completing
a project?
Do you tend to delay certain activities?
Do you have difficulty in setting priorities?
Do you become impatient quickly?
Do you often feel nervous or anxious?
Do you have difficulties with time management?
Do you have difficulty in finding objects at
home or at work?
Do you act before thinking about consequences?
Do you speak before you think about the impact your words have on others?
Do you tend to have lots of thoughts?
Are you easily bored?
Do you make mistakes when working on a
boring or difficult project?
Do you take risks often?
3

Low, K., 2009, Wondering If You Have Adult ADD?, About.com Guide, April 11

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Camelia Stanciu Syndrome of adhd in adults - diagnostic criteria and intervention

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
48

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inappropriate (in adolescents or adults may be


limited to subjective feelings of restlessness);
d. often has difficulty playing or participating in
leisure activities quietly;s
e. is frequently on the go or acts as if it plugged;
f. often talks excessively.
Impulsiveness
a. often misses the answers before the questions
are completely formulated;
b. often has difficulty awaiting turn;
c. to interrupt or disturb others frequently (eg.,
enter into conversation or games).
d. Some symptoms of hyperactivity-impulsivity
or inattention that led to problems were present before age 7 years.
e. Difficulties due to these symptoms are present
in two or more circumstances: at school (or
work) at home.
f. There must be clear evidence of significant deterioration in the performance of social, academic or occupational.
g. The symptoms do not occur exclusively during
a pervasive developmental disorder (PDD),
schizophrenia or other psychoses and may
not be associated with other mental disorders
(such as neuroticism, anxiety, dissociation or a
personality disorder).
Codes based on the type of ADHD:
314.01 attention deficit hyperkinetic disorder together, combined type: if both criteria (A1 and A2)
occurred in the last 6 months.
314.00 attention deficit hyperkinetic disorder
accompanied, predominantly inattentive type: if A1
crietriul manifested in the last six months, but no criterion A2.
314.01 attention deficit hyperkinetic disorder
accompanied, predominantly hyperactive-impulsive type: if criterion A2 was expressed in the last six
months, but no criterion A1.
Note: Individuals who currently have symptoms
that fit the criteria only partially (especially adolescents
and adults) must be specified in partial remission.
314.9 Disorder with hyperactivity and attention
deficit without further specification
This category is for disorders with symptoms of
inattention or hyperactivity notable-impulsivity that
do not meet criteria for attention deficit hyperkinetic
disorder together.
Utah criteria (Wender, 1995, 2000) to assess
ADHD in adults:

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Camelia Stanciu Syndrome of adhd in adults - diagnostic criteria and intervention

History of childhood consistent with ADHD;


Symptoms specific
Hyperactivity and poor concentration
emotional lability
Impulsiveness
Inability to complete tasks and disorganization
low frustration tolerance
Utah criteria include in their composition and
emotional aspects. Impulsive episodes, characterized
by rash temperament are quickly forgotten by the
person concerned, but are more difficult to forget by
colleagues or family members.
Emotional lability is characterized by short bursts,
intense and range from euphoria to anger and despair.
Other manifestations of adults with ADHD include attribution of the following 5 dimensions:
Activity and organization (refers to the difficulties met by the person in organizing the
daily tasks);
Sustained attention (includes issues such as:
distraction, daydreaming);
Sustainable energy and effort (feeling of drowsiness, low degree of completion of the tasks);
Managing affective interference (low motivation, irritability, low tolerance to frustration);
Working memory and the ability to update information (low performance);
P. Wender4) (1996) conducted an extensive study
on 300 patients with ADHD, using within the experimental group, psychostimulants like: Methylphenidate (Ritalin), Pemoline (Cyclert), L-deprenyl
(Selegiline), Bupropion (Wellbutrin), Levodopa, Dlphenylalanine and L-tyrosine, and in the case of the
control group the placebo treatment. The author
found that approx. 60% of the patients receiving stimulant medication show significant improvements,
in comparison to only 10% of the control group who
received the placebo treatment. The results of the two
groups were assessed using the Global Assesement
of Functioning (DSM-IV). among all the substances
administered, major effects were found following the
administration of Methylphenidate, Pemoline and
MAO inhibitors.
A complete treatment for adults with ADHD
involves informing these people about the disorder
and presenting the therapeutic matrix explaining the
advantages and disadvantages of drug administration.
Among the changes that patients may experience after drug administration, Wender lists:
4

Wender, P.,1996, ADHD in Adults, Psychiatric Times, vol. 13. no. 7, p. 7-9

reducing motor agitation; patients are able to


relax, to sit for a longer period of time at the
office or while watching a movie;
the ability to concentrate improves significantly; increase of patients attention to conjugal
conversations and thus, reduction of marital
conflict;
to reduce the moments of boredom; the mental state is described as stable;
patients become less irritable, outbursts of anger are reduced in frequency and intensity, to
extinction;
improvement of the organizational capacity (at
school, at the workplace, at home);
are able to overcome life problems, becoming
more secure when facing difficult situations;
improves the ability to listen to conversations
of others, become more tolerant in traffic, an
increase in self-control in social situations.
The Treatment of adults with ADHD often includes stimulants. These present loke side effects an
increase of the blood pressure and pulse, which could
lead to strokes and heart attacks. Before initiating any
treatment, adults with ADHD should receive a full
medical examination (Austin5) et al, 2007).
1.3. Etiology, mechanisms and
intervention in ADHD:
1.3.1. Neurobiological basis:
Modern methodology of investigation, especially
the so-called functional imaging (fMRI-functional
magnetic resonance imaging, PET - Positron Emission Tomography, SPECT - single positron emission
computed tomography etc.) but also the neurophysiology investigations, including Electroencephalography /
EEG quantitative, evoked potentials or MEG (magnetoEEG) - have made important

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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Camelia Stanciu Syndrome of adhd in adults - diagnostic criteria and intervention

demonstrating a decrease in the prefronal regions and


at the level of the links between these regions and the
limbic system via the striated area, especially at the
level of the caudate nuclei (Himelstein et al, 2000;
Brennan and Arnsten, 2008; Arnsten et al, 2009).
Also, the studies that use the PET to evaluate the
cerebrale glucoses metabolism (see picture 1) have
demonstrated its decrease on adults, (Zametkin et
al. 1990), but also on teenagers with ADHD. There

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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.

Figure 2. The right brain hemisphere indicating cortical areas


mainly involved in the ADHD determination
(Barkley, 2006 a i 2006 b).

Figure 1. The analyze of the cerebral activity using PET on


people with ADHD and without ADHD (after Zametkin et
al,1990). In the right side of the image it can be noticed that
individuals with ADHD have a less intense brain activity than
those without this disorder concerning the activity control. The
medical treatment aims to actrivate these control centers.

were found differecences in teenage boys and girls,


yet unexplained, between the aspects of the cerebral
metabolism in ADHD (Ernst et al., 1997; 1998).
In addition, there were found significant functional
asimmetry of diffrent cerebral areas, for example, a
reduced metabolic activity in the left anterior frontal region, strongly correlated with the severity of the
ADHD symptoms (Zametkin et al, 1990), which
confirms the bond between the cerebral activity of a
certain region and the typical behavior that individuals with ADHD have (express).
Studies based on a simple CT exam havent identified a signifiant difference between children and normal adults and the ones with ADHD, but it was noticeable a high brain atrophy in adults with ADHD
that have a history of substance abuse. This abuse explaines better the atrophy than ADHD does (Barkley,
2006 b).
A much more sensitive analysis of the brain structures based on the MRI and fMRI reveales a number
of differences in some cortical areas between normal
50

Hynde et al. (1993) sustain that children with


ADHD caudate region of the left hemisphere is less,
having a reverse configuration than a normal children.
If at normal people left hemisphere caudal nucleus
are higher than those in the right hemisphere, at children with ADHD this configuration is not observed.
Hyndes results (1993) are consistent with studies
that found decrease local blood flow in these regions. Similar studies using quantitative MRI, indicates
a smaller frontal area of the right hemisphere and a
smaller size of the caudate nucleus and globus pallidus at children with ADHD, compared with normal
children (Castellanos et al, 2002). The same authors
had identified a lower volume of the cerebellum in
ADHD than normal, which is consistent with recent
research that assigns a major role in cerebellum motor manifestation of aspects from planning work and
other executives.
A particular aspect of these studies refers to the
size of caudate nucleus, which is lower at children
with ADHD than in normal ones; but there is no
consensus regarding which specific part of the nucleus is smaller. Hynde et al. (1993), Ernst et al (1998),
Giedd et al (2001), identify the left caudate nucleus
to be smaller; and Castellanos et al. (1996 and 2002)
identifies the caudal nucleus more atrophic in the right side. Brains of normal people have a front region
of constant asymmetry of the hemispheres, the right
one is larger than the left one (Giedd et al, 2001). This
argument led Castellanos to claim that lack of this
asymmetry may mediate specific events for ADHD.

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Camelia Stanciu Syndrome of adhd in adults - diagnostic criteria and intervention

It is important to note that none of neuroimaging


studies have identified that people with ADHD have
brain damage. The aspects described in these studies
refer only to some of the size of brain areas, most of
the times missing asymmetry (the frontal regions or
the caudate and globus pallidus nucleus), while these
asymmetries are found in normal individuals. When
deficits are identified at the cerebral level, most often
they are the result of abnormalities arising in the development of these cerebral regions most likely causes
are genetic. Finally, genes determine largely cerebral
development (Barkley, 2006, 2006 b, 2008).
Research of brain neurochemistry, explosive developed early 90s showed that ADHD symptoms are
caused by a neurophysiological dysfunction of the
brain. Various studies using PET and SPECT have
confirmed that there is a clearly defined difference
between individuals with ADHD and those without.
ADHD based mechanisms are complex and are further investigated.
It was found that the brain chemical balance is
unbalanced and neurotransmitters, especially Dopamine (and Norepinephrine, Serotonin, Glutamate)
and their receptors are in low quantities in certain
brain regions, usually asymmetric, those with ADHD,
not only in the cortex, but also in subcortical nucleus, limbic system, cerebellum and brainstem. Several
authors have documented these issues and their correlation functions of certain psychological and behavioral changes in ADHD (Zametkin 1990; Murphy
and Barkley, 1996; Ernst et al, 1998; Carlsson et al,
2000; Comings et al, 2000; Himelstein et al, 2000;
Roth and Saykin, 2004; Arnsten et al, 2009). Thus, it
was found that, for example, right prefrontal cortex is
involved in editing behavior and resistance to fun.
Caudate nucleus and pale globe help automatically to
extinguish the response, to allow for deliberation of
the cortex and to synchronize neurological input in
various regions of the cortex. The exact role of vermish
is not clear, but studies made so far, suggest that is involved in planning and motivation. However, the major role appears to be owned by impaired of prefrontal
cortex, for cerebral blood flow is decreased by 65% at
children with ADHD during intellectual effort, compared with normal children.
All within the possible causes of the disorder, we
could remember an experiment that demonstrated a
link between a persons ability to pay attention and
the activity level of the brain. To the subjects participating to the experiment were given to memorize

a list of words. It was used PET to measure level of


glucose used by areas that inhibit impulses and control attention. Glucose is the main source of brain
power. The researchers found significant differences
between people with and without ADHD. In those
with ADHD they found a lower level of consumption of glucose, whence the existence of a much lower
level of activity in some parts of the brain, which might cause distraction.
It was assumed and confirmed that the basis of the
pathogenesis of the syndrome are disorders of activation of reticular formation, which helps coordinate
learning and ability to maintain attention. Disorders
of the activation function of reticular formation are
related to the shortage of noradrenaline. Failure of
adequate processing leads to a situation where different visual stimulus, sound, emotional become superfluous for the children, causing restlessness, agitation
and aggression. In fact, years ago, Dr. Paul Wender6)
(Wender, 1996) advanced the theory, according to
which that MBD may have a genetic origin, being
produced by a decrease of catecolaminergice functioning. Some biochemical studies performed on children with this syndrome have shown that not only
is disturbed metabolism of Dopamine, but also other
neuromediators - Serotonin and Norepinephrine.
1.3.2. Genetic studies:
Recent discoveryes in genetics, especially molecular genetics have demonstrated the involvement of
several genes in the genesis of ADHD. Undoubtedly,
ADHD is a genetic disorder polygenic, in which
only one gene is affected. This conclusion was reached otherwise and empirically researching families
of children with ADHD; for childrenwho come from
families affected are 5-7 times more likely to develop disease than those from unaffected families and
children who have a parent with ADHD are likely
to provide 50% syndrome. In addition, twin studies
have shown that 80% of differences in terms of attention, hyperactivity and impulsivity between people
who have ADHD and those who do not have, can be
explained by genetic factors. Factors that are linked to
ADHD, but do not have a genetic substrate are: premature birth, consumption of alcohol and cigarettes
during pregnancy, radiation exposure in childhood
and the presence of brain disorders involving the prefrontal cortex. (Comings et al, 2000; Wender, 2000;
Barkley 2006 b; Arnsten et al, 2009).
Studies of psycopathology among families with
6 Wender, P., op.cit., p. 11

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Camelia Stanciu Syndrome of adhd in adults - diagnostic criteria and intervention

hyperactivity and attention deficit cases, studies on


adoption and studies on twins have suggested the
presence of a genetic contribution in the etiology of
this disorder. Primary records have revealed that the
fathers of hiperactive children show a high incidence
of alchoholism, sociopathy and a history of childhood
laden with learning dificulties and behavioral disorder. It was also pointed out a correlation between the
ADHD symptoms and early consumption of alcohol
among children who come from alcoholoic families.
The syndrome of attention deficit and hyperactivity (ADHD) is considered to be highly influenced by
the genetic factor, because- besides the many studies
on twins that reveal that the global imaturity is a part
of the genetic effects of the ADHD both in girls and
in boys, it was also discovered the presence of many
parental factors that interfere (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): genetics (the way the affection is given) and educational (behavioral patterns,
aspects of the attachment, the ability to offer rewards
and to respect rules- coming from the parents with
ADHD and the normal parents that have chldren
with ADHD).
1.3.3. The importance of the environmental factors:
The capacity to sustain an efficient level of intelectual and affective concentration derives, at least partially, from the parents ability to strengthen the pursuit
of meaningful goals. It was acertained that children
who come from chaotic organized families fail to develop this capacity. The attention of a child can be pieced due to an extremly distractable environment or by
an anxiety (mostly related to the performance in difficult school tasks). Also, internal psychological conflicts
can determinate the attentions orientation inward and
disturbances of the attentional mechanisms.
Even if this idea is not accepted nowadays, many
years before, it was beleived that there is a bond
between hyperactivity and diet. This theory presented a high level of credibility based on the parents
reports, describing their childrens behavioral reactions after eating a certain foodstuff. Recent researches
have not indicated the existance of a scientific support
for this theory.
1.3.4. The psychological context:
The psychomotor instability charcteristic to the
ADHD syndrome can be a part of a traumatic situation. The more the child is smaller as age, the more the
way he/she expresses a motric difficulty or a mental
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tension passes more easily through the body causing


a reactional tension. A 2-3 years old child, and even
older presents a natural instability, common, expressed through a week attention and explosive motricity,
often related to the multiplication of the experiences
and discoveries. Unfortunately, the entourage does
not easily accept this type of demeanor (behaviour).
Faced with the intolerant attitudes of the environment, the child with motric instability can exacerbate
his/her symptoms and manifestations. Therefore, it
appears the question of the environments intolerance
level, especially the familys, towards the psycomotor
symptoms. This level is very low in the families where one or both parents have ADHD. The educational
and psycological intervention, formative- or therapeutic, but also couseling regarding the change in the
parental pattern (if necessary) este often required and
benefic, both for the adult with ADHD and the child
or the entire family.
1.3.5. Prognosis:
ADHD syndrome represent an important issue in
public health. Its prevalence varies between 4% AND
19%, depending on what criteria are used (Taylor, 1994).
The prognosis is bad, because reaching the adlut
life, individuals with ADHD show a high risk of delinquency, criminality, drugs abuse, family and professional failure, and other difficulties in social adjustment. It was highlighted that the children from
families that have a very low economical status and
the boys, are generally likely to develop this syndrome.
1.3.6. Psychological mechanisms used in psychotherapeutic intervention
Specialists are trying to find out how the brain
structure and the observed genetic abnormalities on
ADHD children are ralated to the behavioral characteristics of this disorder?
How structural and genetic anomalies identified
at ADHD childrens is correlated with behavioural
characteristics of this disorder ? How can we intervene with psychotherapy on children to prevent the
persistance of the disorder at the adult age?
Barkley (2006 a; 2006 b; 2008) have concluded
that in ADHD the central deficit refers to the behavioral inhibition and self-control.
Self-control or the capacity of inhibition / delay of
the initial motor response at a certain event represents
a critical substantiation for any kind os task. Childre
that are in the process of growing gain the capaity
to exercise control on the mental activities, on the
executive functions, hepling them to ignore the dis-

Journal of Romanian Child and Adolescent Neurology and Psychiatry 2012 15th vol. no. 2

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Camelia Stanciu Syndrome of adhd in adults - diagnostic criteria and intervention

tractable factors, renaming the aims and following the


necessary steps for accomplishement. Accompleshing
a goal either in a game or in work, individuals must be
capable to remind themself the goal, to master their
emotions and corectly channel the motivation.
Executive functions that interfere in this process
(Roth and Saykin, 2004; Schmidt et al, 2002) can be
grouped in four mental activities, whose practice is
manadtory in the psycotherapeutic intervention- to
prevent perpetuation of the disorder from the child
age to the aduld age:
Working memory - keeps informations during the
execution of a task, even if the initial stimulus that
provided the information is missing. This evocation is crucial for the goal-directed behaviour; it
provides ways to imitate the others new and complex behaviour (all these aspects are seen in individuals with ADHD).
The internalization of the language- represents an
other executive function. Before the age of 6, children
talk to themselves out loud, frequently reminding
how did thei accoplished a particular task in the attempt to solve a problem. The internalization, the

self-directing speech allows them to reflect on itself,


to follow rules and instructions, to use self-questioning as a form of solving a problem and aquire the
ability to build meta-rules (the foundation for understanding and usage of the rules). It has been shown
that the internalization of the self-directing speech
is delayed at children with ADHD.
Control of t he emotions, motivation and arousal state - represents the third executive function involved
Reconstruction - the last of the executive function
used to aquire self-control accompanies two separate
processes: suppression of the observed behaviour and
the combination of the parts in new actions which are not learned from previous experiences. The
capacity of reconstruction offers the individuals a
high level of influenece, flexibility and creativity; all
these allowing humans to concentrate on a certain
aim, without mechanical storage of the required steps.
This aspect allows the child to self-direct his/
her behaviour along the increasing intervals by
combining the behaviours in a long chain, in order to
achieve the goal.

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Journal of Romanian Child and Adolescent Neurology and Psychiatry 2012 15th vol. no. 2