Silzá Tramontina

ADHD in a school sample of Brazilian adolescents : A study of prevalence, comorbid conditions, and impairments

OBJECTIVE To evaluate the prevalence, comorbid conditions, and impairments of attention-deficit/hyperactivity disorder (ADHD) among young adolescents in Porto Alegre, Brazil. METHOD 1,013 students aged 12 to 14 years were evaluated at 64 state schools, using a screening instrument based on the 18 DSM-IV ADHD symptoms. All positive screened students (n = 99) and a random subset of negative screened subjects (n = 92) had a psychiatric evaluation carried out within a hospital setting or at home. RESULTS The prevalence of ADHD was estimated to be 5.8% (95% confidence interval = 3.2-10.6), and the comorbidity with other disruptive behavior disorders was high (47.8%). Youths with ADHD (n = 23) had significantly higher rates of school repetitions, suspensions, and expulsions (p < .01) than controls (n = 168). No association was identified between ADHD and alcohol, marijuana, and inhalant use. CONCLUSION The results extend to adolescents well-documented findings in children, indicating that ADHD is quite prevalent in early adolescence and affected youths are at high risk for impairment and dysfunction in multiple domains.

Attention-Deficit/Hyperactivity Disorder in a Diverse Culture: Do Research and Clinical Findings Support the Notion of a Cultural Construct for the Disorder?

There is still some debate in the literature whether Attention-Deficit Disorder/Hyperactivity (ADHD) is best conceptualized as a biological disorder or if it is best understood as a cultural construct. This review aims to contribute to disentangle this issue assessing clinical and research data on ADHD in a complete diverse culture from a developing country. We performed a systematic computerized review of the literature on ADHD in Brazil. All investigations were included if dealing with ADHD prevalence, etiology, symptomatological construct, or treatment. Findings were compared to those from studies in developed countries. The prevalence rates of ADHD (5.8% using DSM-IV criteria, 1.5% using ICD-10), the bi-dimensional factor construct extracted from factor analyses (inattention and hyperactivity/impulsivity), the pattern of ADHD comorbidity in clinical samples, the family genetic data suggesting a 39% family transmission in clinical samples and the role of some potential candidate genes in dopaminergic and noradrenergic systems, as well as data on the efficacy of methylphenidate in the disorder are all very similar to findings from developed countries. Taken together, these findings suggest that ADHD is not a cultural construct, reinforcing the importance of applying similar research methodology in different cultures to make findings comparable.

Transtorno de déficit de atenção/hiperatividade

Introducao As primeiras referencias aos transtornos hipercineticos na literatura medica apareceram no meio do seculo XIX. Entretanto, sua nomenclatura vem sofrendo alteracoes continuas. Na decada de 40, surgiu a designacao “lesao cerebral minima”, que, ja em 1962, foi modificada para “disfuncao cerebral minima”, reconhecendo-se que as alteracoes caracteristicas da sindrome relacionam-se mais a disfuncoes em vias nervosas do que propriamente a lesoes nas mesmas. Os sistemas classificatorios modernos utilizados em psiquiatria, CID-10 e DSM-IV, apresentam mais similaridades do que diferencas nas diretrizes diagnosticas para o transtorno, embora utilizem nomenclaturas diferentes (transtorno de deficit de atencao/hiperatividade no DSMIV e transtornos hipercineticos na CID-10). Os estudos nacionais e internacionais situam a prevalencia do transtorno de deficit de atencao/hiperatividade (TDAH) entre 3% e 6%, sendo realizados com criancas em idade escolar na sua maioria. O impacto desse transtorno na sociedade e enorme, considerando-se seu alto custo financeiro, o estresse nas familias, o prejuizo nas atividades academicas e vocacionais, bem como efeitos negativos na auto-estima das criancas e adolescentes. Estudos tem demonstrado que criancas com essa sindrome apresentam um risco aumentado de desenvolverem outras doencas psiquiatricas na infância, adolescencia e idade adulta. A presente atualizacao busca uma revisao critica dos elementos essenciais referentes ao diagnostico e as abordagens terapeuticas do TDAH. Uma revisao mais completa (porem menos atualizada) incluindo dados epidemiologicos, etiologicos, relacionados ao substrato neurobiologico e de evolucao do transtorno podem ser encontrados em Rohde et al. (1998). No presente artigo, o termo crianca sera utilizado englobando a faixa etaria da infância e adolescencia, a menos que seja indicado o contrario.

Aripiprazole in children and adolescents with bipolar disorder comorbid with attention-deficit/hyperactivity disorder: a pilot randomized clinical trial.

OBJECTIVE To assess response to treatment with aripiprazole in children and adolescents with bipolar disorder comorbid with attention-deficit/hyperactivity disorder (ADHD). METHOD Children and adolescents were extensively assessed according to DSM-IV criteria for bipolar disorder comorbid with ADHD (n = 710). Those with this comorbidity who were acutely manic or in mixed states were randomly assigned in a 6-week double-blind, placebo-controlled trial to aripiprazole (n = 18) or placebo (n = 25). Primary outcome measures were assessed weekly and included the Young Mania Rating Scale; the Swanson, Nolan, and Pelham Scale-Version IV; and weight. Secondary outcome measures were the Clinical Global Impressions-Severity of Illness scale, the Child Mania Rating Scale-Parental Version (CMRS-P), the Childrens Depression Rating Scale-Revised, the Kutcher Adolescent Depression Scale, and adverse events. The trial was conducted at the Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brazil, from January 2005 to November 2007. RESULTS The group receiving aripiprazole showed a significantly greater reduction in YMRS scores (P = .02, effect size [ES] = 0.80), CMRS-P scores (P = .02; ES = 0.54), and CGI-S scores (P = .04; ES = 0.28) from baseline to endpoint than the placebo group. In addition, higher rates of response (P = .02) and remission (P = .01) were found for the aripiprazole group. No significant between-group differences were found in weight, ADHD symptoms, and depressive symptoms. Adverse events significantly more frequent in the aripiprazole group were somnolence and sialorrhea. CONCLUSION Aripiprazole was effective in reducing manic symptoms and improving global functioning without promoting severe adverse events or weight gain. No significant treatment effect in ADHD symptoms was observed. Studies are needed to assess psychopharmacologic interventions for improving ADHD symptoms in juvenile bipolar disorder comorbid with ADHD. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00116259.

Methylphenidate Combined with Aripiprazole in Children and Adolescents with Bipolar Disorder and Attention-Deficit/Hyperactivity Disorder: A Randomized Crossover Trial

In clinical samples, juvenile bipolar disorder (JBPD) is frequently accompanied by co-morbid attention-deficit/hyperactivity disorder (ADHD). Clinical trials assessing combined psychopharmacological interventions in this population are scarce, and methylphenidate (MPH) may worsen manic symptoms. We conducted a randomized crossover trial with MPH and placebo (2 weeks each) combined with aripiprazole in children and adolescents (n = 16; 8-17 years old) with JBPD and ADHD who had a significant response in manic symptoms with aripiprazole but still presented clinically significant symptoms of ADHD. ADHD, manic, and depressive symptoms were assessed by means of standard scales. Fourteen out of the 16 subjects completed the trial. No significant differences between the effects of methylphenidate and placebo were detected in ADHD (F(1, 43.22) = 0.00; p = 0.97) or manic (F(1, 40.19) = 0.93; p = 0.34) symptoms. Significant improvement in depressive symptoms was observed in the MPH group (F(1,19.03) = 7.75; p = 0.01) according to a secondary self-reported outcome measure. One patient using aripiprazole and MPH discontinued the trial due to the onset of a severe mixed episode. No other significant adverse events were observed. Although MPH did not worsen manic symptoms, it was not more effective than placebo in improving ADHD symptoms in children and adolescents with JBPD co-morbid with ADHD stabilized with aripiprazole. Further investigations are warranted. This study is registered at www.clinicaltrials.gov under the identifier NCT00305370.

Juvenile bipolar disorder in Brazil: clinical and treatment findings.

BACKGROUND Because few studies were conducted to evaluate bipolar disorder in children and adolescents outside North America, this investigation aims to describe clinical features, pattern of comorbidities, and response to pharmacologic treatment in a sample of youths with bipolar disorder (BD) from a pediatric psychopharmacology outpatient clinic in Brazil. METHODS We performed a retrospective chart review of all patients under age 15 with BD diagnoses who were evaluated and treated in our clinic from 1998-2001. A comparison sample of subjects with attention-deficit/hyperactivity disorder (ADHD) without BD (n = 362) was also evaluated. RESULTS The prevalence of juvenile BD in our sample was 7.2% (36/500) (95% confidence interval = 5.2-9.9). Irritable mood was detected in 91.7% of the bipolar patients. The main comorbidity found was ADHD (58.3%). Children with BD had significantly higher rates of abnormally elevated CBCL scores in the externalizing dimension, anxiety and depression, delinquent behavior, and aggressive behavior scales than ADHD subjects (p <.05). Most BD patients (78%) needed combination drug therapy to achieve symptomatic control. CONCLUSIONS Our results replicate clinical and treatment findings from U.S. investigations in a different culture demonstrating that juvenile BD is not a rare disorder in clinical samples.

School dropout and conduct disorder in brazilian elementary school students

Objectives: To evaluate the association between DSM-IV conduct disorder (CD) and school dropout in a sample of students from the third and fourth elementary grades at state schools in the capital of the southernmost state of Brazil. Methods: In this case-control study, students that dropped out of schools (n = 44) and a control group who continued attending schools (n = 44) were assessed for CD and other prevalent mental disorders, using the Schedule for Affective Disorders and Schizophrenia for School Age Children, Epidemiological Version (K-SADS-E). Results: The prevalence of DSM-IV CD was significantly higher in the school-dropout group than in control subjects (P < 0.001), both in the entire sample and in a subsample including only subjects under age 12 years (P = 0.001). Also, the odds ratio (OR) for school dropout was significantly higher in the presence of DSM-IV CD, even after controlling for potential confounding factors (age, estimated IQ, school repetition, family structure, and income) (P < 0.01). Conclusion: Our results extend to children and young adolescents previous findings from studies of older adolescents, suggesting an association between school dropout and CD.

Diagnostic Performance of the CBCL-Attention Problem Scale as a Screening Measure in a Sample of Brazilian Children with ADHD.

Objective: To evaluate the diagnostic performance of the Attention Problem Scale of the Child Behavior Checklist (CBCL-APS) for the screening of Attention-Deficit/Hyperactivity Disorder (ADHD) in a sample of Brazilian children and adolescents. Methods: The CBCL-APS was given to 763 children and adolescents. Child psychiatrists using DSM-IV criteria confirmed the clinical diagnoses. Diagnostic performance was evaluated through Receiver-Operating Characteristic (ROC) curves. Results: Only moderate areas under the curve (AUC) were found for the general sample (AUC = 0.79; 95%CI = 0.76-0.82), and for the subsample of referred patients (AUC = 0.78; 95%CI = 0.74-0.82). The subsample of patients with ADHD of the combined type presented the largest AUC (AUC = 0.85; 95%CI = 0.82-0.88). Conclusion: Our findings concur with previous studies of different cultures demonstrating adequate diagnostic performance of the CBCL-APS for the screening of ADHD, especially of the combined type.

An Open-Label Trial of Risperidone in Children and Adolescents with Severe Mood Dysregulation

OBJECTIVE The diagnosis and treatment of youth with severe nonepisodic irritability and hyperarousal, a syndrome defined as severe mood dysregulation (SMD), has been the focus of increasing concern and debate among clinicians and researchers. Our main objective was to assess the effectiveness of risperidone for youths with SMD. METHODS An 8-week open label trial with risperidone was conducted. We extensively assessed 97 subjects with semistructured and clinical interviews and enrolled 21 patients in the study. Risperidone was titrated from 0.5 to 3 mg/day in the first 2 weeks. Evaluations were performed at baseline and weeks 2, 4, 6, and 8. Clinical outcome measures were (1) Aberrant Behavior Checklist-Irritability Subscale, (2) Clinical Global Impressions, and (3) severity of co-morbid conditions. RESULTS We found a significant reduction of the Aberrant Behavior Checklist-Irritability scores during the trial after risperidone use (p < 0.001). The scores at week 2 (mean = 12.03; standard error [SE] = 2.94), week 4 (mean = 15.48; SE = 2.93), week 6 (mean = 12.29; SE = 2.86), and week 8 (mean = 11.28; SE = 3.06) were significantly reduced compared with the baseline mean score (mean = 25.89; SE = 2.76) (p < 0.001). We also found an improvement in attention-deficit/hyperactivity disorder, depression, and global functioning (p < 0.001). CONCLUSION Risperidone was effective in reducing irritability in SMD youth. To the best of our knowledge, this is the first psychopharmacological trial in this group of patients with positive results. Further randomized, controlled studies are needed.

Maternity blues in Brazilian women

In this prospective study, a sample of 86 postpartum women was compared with a sample of 75 women from a random period of 8 consecutive days out of puerperium. Symptoms were evaluated each day using the Blues Questionnaire. Postpartum women and women out of puerperium showed a different distribution of percentile scores on the scale on the third, fourth and fifth days. The postpartum symptom peak occurred on the fifth day. Symptoms more significantly associated with the third, fourth and fifth postpartum days were overemotionalism and oversensitivity. It is concluded that maternity blues in Brazilian women appear to be characterized by maternal mental state alterations occurring on the third, fourth and fifth days postpartum. MB seems to be better defined as an emotional oversensitivity syndrome of cross‐cultural dimension than as depression.