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Module ADHD
ADHD
l’entit&agrav= e; del problema
Cenni storici
Definizione
Criteri diagnostici
Epidemiologia
Neurofisiopatologia
Comorbilità
Decorso e prognosi
Genova, 15/11/2008
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ADHD
che cos= a se ne sa
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Definizione fisiopatologico-clinica
Il Disturbo da Deficit dell’Attenzione e
Iperattività è un disturbo neurobiologico della
corteccia prefrontale e dei nuclei della base che
si manifesta come alterazione nella
elaborazione<= span lang=3DIT style=3D'font-family:Arial;mso-ascii-font-family:Arial;mso-farea= st-font-family: "Arial Unicode MS";mso-bidi-font-family:"Arial Unicode MS";mso-hansi-font-= family: Arial;font-size:142%;mso-fareast-language:KO'> delle risposte agli stimoli
ambien= tali ed è caratterizzato da inattenzione,
impulsività, iperattività
•<= /span>Swanson et al. 1998
•<= /span>DSM-IV, 2000
•<= /span>Linee guida SINPI= A, 2004
Il Dis= turbo da Deficit dell ’Attenzione e  Iperattività è un disturbo neuropsichiatrico a esord= io in età evolutiva caratterizzato da inattenzione, impulsività= ; e iperattività motoria.
L&#= 8217;Inattenzione o facile distraibilità, si manifesta soprattutto come scarsa cura = per i dettagli ed incapacità a portare a termine le azioni intraprese:= i bambini appaiono costantemente distratti come se avessero sempre altro in mente, evitano di svolgere attività che richiedano attenzione per i particolari o abilità organizzative, perdono frequentemente oggetti significativi o dimenticano attività importanti.
I proc= essi percettivi non sembrano alterati
Il def= icit dell’attenzione sostenuta sta nel modo in cui i b.ni prestano attenzione (non se la prestano o no)
Si man= ifesta principalmente quando gli stimoli sono distribuiti nel tempo ed è accentuata dalla scarsa motivazione per compiti sgraditi o non interessan= ti
=3D distraibilità che comporta ridotta perseveranza in un compito o in= un gioco, > dell’orientamento verso stimoli esterni
L&#= 8217;impulsività si manifesta come difficoltà, ad organizzare azioni complesse,= con tendenza al cambiamento rapido da un’attività ad un’al= tra e difficoltà ad aspettare il proprio turno in situazioni di gioco = e/ attività di gruppo
Essere= impulsivi significa agire senza riflettere e fallire nella pianificazione
I.motoria: esplosione di reazioni con brevi tempi di = reazione
I. cog= nitiva: processo di pianificazione=3DComporta problemi nell’organizzaz del comportamento, dimenticanze ed inefficiente uso del tempo
Ipe= rattività: irrequietezza agitazione > dei movimenti grossolani del corpo i b.ni si muovono con una frequenza doppia “mossi da un motorino” ma il loro schema motorio è meno complesso e lineare
 hanno difficoltà a rispett= are le regole, i tempi e gli spazi dei coetanei, a scuola trovano spesso diffici= le anche rimanere seduti.
Tutti = questi sintomi non sono dovuti a deficit cognitivo ma a difficoltà oggettive nell’autocontrollo e nella capacità di pianificazione.
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Cenni stor= ici
<= span class=3DBB style=3D'position:absolute;left:-2.62%;top:.22em'>¨<= span lang=3DIT>1902 Still Iperattività
¨ Sdr di Kramer-Pollnow
¨ Disturbo Ipercinetico
¨ Disfunzione Cerebrale Minima (DCM)
<= span class=3DBB style=3D'position:absolute;left:-2.62%;top:.22em'>¨<= span lang=3DIT>1966 ICD 8 Reazione Ipercinetica dell’Infanzia
<= span class=3DBB style=3D'position:absolute;left:-2.62%;top:.22em'>¨<= span lang=3DIT>1968 DSM II<= span style=3D'mso-tab-count:2;width:11.94%'> Reazione Ipercinetica dell’Infanzia
¨1980 DSM III= Disturbo da Deficit di Atte= nzione con o senza Iperattività (ADDH o ADD)
<= span class=3DBB style=3D'position:absolute;left:-2.62%;top:.22em'>¨<= span lang=3DIT>1987 DSM III= -R ADHD
<= span class=3DBB style=3D'position:absolute;left:-2.62%;top:.22em'>¨<= span lang=3DIT>1992 ICD 10<= span style=3D'mso-tab-count:2;width:11.76%'> Disturbo Ipercinetico <= /span>
<= span class=3DBB style=3D'position:absolute;left:-2.62%;top:.22em'>¨<= span lang=3DIT>1994 DSM IV<= span style=3D'mso-tab-count:2;width:10.81%'> ADHD (tre sottotipi)
<= span class=3DBB style=3D'position:absolute;left:-2.62%;top:.22em'>¨<= span lang=3DIT>2000 DSM IV-= TR ADHD (       “        = ;  ) <= /span>
¨<= span lang=3DIT style=3D'font-size:90%'>(Dell’Agnello et al., 2007)
Un cluster sintomatologico simile a ciò che oggi definiamo ADHD pedia= tra inglese Sir George Still: deficit di attenzione e controllo morale in B.ni senza IM o lesioni cerebrali
L’inattenzione, l’iperattività e l’impulsività NON venivano migliorate da metodi punitivi
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Secondo i cri= teri del DSM-IV la diagnosi di ADHD richiede la presenza di:
• 6 o più sintomi della sfe= ra dell’iperattività/impulsività
   (sottotipo prevalentemente iperattivo/impulsivo)
op= pure
• 6 o più sintomi della sfera dell’inattenzione
  (sottotipo prevalentemente inattentivo)
op= pure
• 6 o più sintomi di disatten= zione e 6 o più sintomi di
  iperattività/impulsivit&ag= rave; (sottotipo combinato)
CRITERI DIAGNOSTICI
•<= /span>Adapted from American Psychiatric Association, DSM-IV, 2000 =
•Linee guida SINPIA, 2004
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Distribuzione dei Sottotipi Clinici del DSM IV
50-75%
20-30%
< 15%
Tipo Combinato
Prevalentemente
Iperattivo / Impulsivo
Prevalentemente
Inattentivo
•Adattato dall’American Psychiatric Association, DSM-IV TR, 2000
•Barkley RA. Attention-deficit/hyperactivity disorder. In: Mash EJ, Barkley RA, eds. Child Psychopathology  1996;63-112
Prevalentemen= te Inattentivo:
• Facilmente distraibile
• Ma non eccessivamente iperattivo / impulsivo
Prevalentemen= te Iperattivo / Impulsivo:
• Estremamente Iperattivo / Impulsivo
• Può non avere sin= tomi di inattenzione
• Frequentemente bambini piccoli
Sottotipo Combinato:
• Maggioranza dei pazienti
• Presenti tutti e tre i s= intomi cardini    <= /span>(Inattenzione, Iperattività/Impulsività)
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ULTERIORI CRITERI DIAGNOSTICI (DSM= IV)
•Adapted from American Psychiatric Association, DSM-IV TR, 2000<= /span> =
•Linee guida SINPIA, 2004
¨<= span lang=3DIT style=3D'font-size:120%;color:white;mso-color-index:1;mso-ansi-l= anguage: EN-US'>Durata <= /span>i sintomi devono durare da almeno 6 mesi
¨<= span lang=3DIT style=3D'color:white;mso-color-index:1;mso-ansi-language:EN-US; display:none'>
¨= ;Età dell’esordio alcuni sintomi devono essere comparsi  prima dei = 7 anni di età
¨<= span lang=3DIT style=3D'color:white;mso-color-index:1;mso-ansi-language:EN-US; display:none'>
¨= ;Pervasività un deficit funzionale dovut= o a tali sintomi deve essere presente in almeno due diversi contesti (es. = scuola, casa)
Secondo i criteri secondo il DSM-IV, per fare diagnosi di ADHD occorre che siano osservabili almeno sei dei nove sintomi di inattenzione e/o iperattività. Che i sintomi esordiscano prima dei sette anni d’età, durino da più di sei mesi, siano evidenti in almeno due diversi contesti della vita del bambino (casa, scuola, ambient= e di gioco) e, soprattutto, causino una significativa compromissione del funzionamento globale del bambino.
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•I criteri diagnostici dell’ICD-10 richiedono:
•Contemporanea prese= nza di comportamento iperattivo (almeno 3 sintomi), marcata inattenzione (almeno 6 sintomi) e impulsività (almeno 1 sintomo)
•Esordio preco= ce (prima dei 7 anni di età)
•Presenza in più di una situazione (casa, classe, ambulatorio)
•Pers= istenza nel tempo (almeno 6 mesi)
•La contemporanea presenza di altri disturbi psichiatrici (es. disturbo oppositivo provocatorio, disturbo della condotta) comporta l’inclusione in specifici raggruppamenti diagnostici (es. Disturbo Ipercinetico della Condotta). =
•L’iperattività e il disturbo dell’attenzione possono presentarsi come manifestazioni di = sindromi ansiose o depressive
ICD-= 10 Sindromi Ipercinetiche
=
World Health Organization (1992). The ICD-10 Classification of Mental and Behavioural Disorders. Clinical Descriptions and Diagnostic Guidelines. Geneva: WHO.
Altri = comportamenti che si possono associare al disturbo ipercinetico sono:
•Comportamento spericolato
•Comportamento impulsivo
•Propensione ad incidenti
•Comportamento disinibito.
Da sol= i, questi comportamenti caratteristici non sono un criterio sufficienti per realizz= are una diagnosi ma possono aiutare a confermare la diagnosi basata sui crite= ri diagnostici.
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+
ICD-10 (HKD) <= /span>
Disturbo Ipercinetico
Inattenzione
Iperattività
Impulsività
+
+
Disturbo Ipercinet= ico
Della condotta=
Disturbo de= lla Condotta <= /div>
DSM-IV (ADHD)<= span lang=3DEN-GB style=3D'font-family:Tahoma;mso-ascii-font-family:Tahoma;mso-= hansi-font-family: Tahoma;font-size:83%;mso-special-format:lastCR;display:none'> <= /span>
ADHD: tipo combinato
Inattenzion= e
Iperattivit= à/Impuslività
+
ADHD: prevalenteme= nte di
Tipo inattentivo
Soltanto Inattenzione
ADHD: prevalentemente di
tipo iperattivo/ impulsivo= 3;
Soltanto Iperattività/Impuslività
Differenza tra i crit= eri diagnostici del
DSM IV-TR e ICD-10
•American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (4th edition, te= xt revision). Washington DC: APA.
•Linee guida SINPIA, 2004
•Tripp G, et al. (1999). J Am Acad Child Adolesc Psychiatry; 38(2): 156-64.
•World Health Organization (1992). The ICD-10 Classification of Mental and Behavioural Disorders. Clinical Descriptions = and Diagnostic Guidelines.
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DSM IV  /  ICD 10: confronto
A seconda del manuale di riferimento, dunque, si formulano diagnosi diverse, e di conseguenza si rilevano dati differenti relativamente alla diffusione del disturbo:
-<= /span> secondo il DSM-IV i pazienti con A= DHD sono circa il 3-5%
-=  secondo l’ICD-10 il disturbo ipercinetico si ritrova nel
  1%-2% della popolazione infantile
Linee guida SINPIA,= 2004
cm
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Quanto è diffuso?
¨
¨ 10% dei problemi comportamentali osservabili in ambito pediatrico (Cantwell, 1996)
¨
¨
¨=  30-50% dei pz che afferiscono ai servizi <= /span>psichiatrici infantili (Popper, 1988
¨ Barkley, 1996)
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Epidemiolo= gia
15.8%
3-18
Nolan, 20= 01
USA=
5.3% = ;
Polanczy= k, 2007
Review= 3;
I: 11.4%&= #13;
G: 3.5%&= #13;
I+G: 1.5= %
6-11 anni<= /span>
Zuddas, 2= 006
Italia
5.65%= 3;
3.06%= 3;
4.33%
Cuffe, 2005
USA= 3;
Afro-amer= icani
Ispanici&= #13;
Bianchi
M: 19.8%=
F: 12.3%=
Pineda, = 2003
Colombia<= /span>
M: 3.62%=
F: 0.85%=
5-15 anni=
Ford, 20= 03
Regno Uni= to
Preva= lenza
Et&agr= ave;
Autor= e
Anno<= /b>
Paese<= /b>
Notevole variabilità della prevalenza spt in funzione dei criteri di inclus= ione utilizzati
-Strumenti di valutazione utilizzati
-Metodologia di selezione del campione
-Età
-Sesso
-Nazionalità Differenze culturali=
-Tipologia della popolazione in esame (r= urale od urbana)
-Tipi di strumenti valutativi utilizzati (questionari, interviste)
-Fonti di informazione (genitori, insegn= anti)
-Inclusione o meno di sogg con comorbilità
-Considerazione o meno della presenza di= deficit funzionali (come necessario e prescritto dai sistemi diagnostici categori= ali)
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Maschi/Fem= mine
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Prevalenza dell’ADHD in popolazioni american= e e non america= ne (criteri DSM)
 (Faraone et coll., 2003)= &= #13;
11,4 = 211; 16,1
16 ̵= 1; 19,8 (n=3D5)
(prevalenza maggiore)
2,4 R= 11; 7,5 (n=3D4)
(prevalenza minore)
8 – 10
7,5 ̵= 1; 11
4
9=
DSM IV
Studi USA
Studi extra USA
7,1 R= 11; 12,8
3,9 R= 11; 10.9
8 – 12
6 –= 11
6
9=
DSM III-R
Studi USA
Studi extra USA
9,1 R= 11; 12
5,8 R= 11; 11,2
9 – 11
7 –= 11
4
7=
DSM III <= /span>
Studi USA
Studi extra USA
Range di
preva= lenza
Range di età
(in an= ni)
N.ro s= tudi
Criteri diagnostici
La prevalenza dell’ADHD, diagnosticata utilizzando i criteri del DSM, nella maggior parte dei b.ni NON americani sia altrettanto elevata di que= lla osservata negli americani
Alcuni degli studi non americani riportati in questa analisi effettuati in Svezi= a, Australia, Islanda, Spagna e Italia hanno mostrato prevalenze piuttosto b= asse (2,4 – 7,5%) ma i dati disponibili NON consentono di concludere che= in queste nazioni la frequenza sia veramente inferiore rispetto a quella di altri paesi
Comparazioni dirette tra diverse popolazioni sono auspicabili per definire la reale prevalenza dell’ADHD in differenti nazioni e condizioni culturali
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Studi epidemiologici italiani
1,5%
Genitori: 3,5%
Insegnan= ti: 11,4%
1500 b.n= i
6 –= 11 anni
 Italia
 (Zuddas, 2006)
7,1%
M: 10,4%=
F: 3,8%<= /span>
1891 b.n= i
al termi= ne della I elem.
 Firenze
 (Mugnaini et al., 2006)
4%
 Umbria e Toscana
 (Gallucci et al., 1993)
 Emilia Romagna
 (Camerini et al., 1996)
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ADHD: Eziologia
ADHD=
Neuroanatomica
Neurochimica
 Fattori biologici acquisiti
Genetica
Fattori Ambientali
•Biederman J, et al. Biol Psychiatr= y. 1999;46:1234-1242.
•La Hoste GJ, et al. Mol Psychiatry= . 1996;1:128-131.
L̵= 7;ADHD è un disturbo neurobiologico ad eziologia multifattoriale.<= br>
1.<= /b>Componente Neurobiologica -> Neuroanat= omica: evidenze strumentali (neuro-imagine), hanno dimostrato l’alterazione dell’attivazione di reti neuronali in soggetti con ADHD come verrà illustrato nelle slide successive. -> Neurochimica: la Noradrenalina (NA) e la Dopamina (DA) sono due dei più importanti neurotrasmettitori correlati alla fisiopatologia ed al trattamento medico dell’ADHD. Nell’ADHD, la disponibilità di questi neurotrasmettitori in specifiche aree del cervello, sarebbe alterata.
2.<= /b>Componente Genetica:
Studi = familiari dimostrano un’alta prevalenza di ADHD e di altri disturbi mentali n= ei parenti dei pazienti.
Studi = sulle adozioni dimostrano una maggiore prevalenza di ADHD nei genitori biologici rispett= o ai genitori adottivi
Studi = sui gemelli dimostrano una concordanza dei sintomi di ADHD in gemelli MZ rispetto a D= Z
Dal pu= nto di vista molecolare, dati promettenti sembrano emergere dagli studi  genetici sul recettore D4  (DRD4) della dopamina.
Esisto= no 5 distinti ricettori dopaminergici codificati da 5 geni e raggruppati in 2 famiglie (D1/D5 e D2/D3/D4)
•La ripetizione dell’allele DRD4- 7 sembra  avere un ruolo nello sviluppo dell’ ADHD. Questa variante recettoriale determinerebbe una ridotta risposta alla  dopamina, e l’mRNA giocherebbe un ruolo sulle funzioni  cognitive ed  emotive.
•E’ stato dimostrato che molti bambini con ADHD  hanno un più alto numero = di ripetizioni dell’allele DRD4-7
•Consistenti con l’ipotesi noradrenergica dell’ ADHD, questi studi dimostrano che sia epinefrina che noradrenalina agiscono come potenti agonisti sul recettore umano D4 della dopamina, suggerendo che farmaci con attività noradrenergica possano modulare sia il sistema noradrenergico che quello dopaminergico.
•E’ importante ricordare però, che molti soggetti con polimorfismo del gene non sono affetti da ADHD e molti bambini con ADHD n= on presentano nessuno dei polimorfismi conosciuti.
3.<= /b> Fattori biologici acquisiti: c’è una forte correlazione tra lo s= tile di vita materno durante la gravidanza ed il rischio di ADHD. Infatti l’esposizione intrauterina a nicotina è l’aspetto più evidente ma anche l’esposizione intrauterina all’alcool sembra mostrare una relazione dose-risposta. Inoltre allergie alimentari, nascita pretermine e basso peso alla nascita cosi co= me disturbi cerebrali (encefaliti, trauma) sono dei fattori correlati all’ADHD.
4. = Fattori ambientali:I seguenti aspetti psicosociali possono modulare l’effetto dei fattori biologici: instabilità familiare, conflitto con il partner, disturbi mentali dei genitori, scarsa competenza dei genitori, rapporto negativo bambino-genitore, basso livello socio-economico


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------=_NextPart_01C94765.54538B00 Content-Location: file:///C:/8EAAA0CF/Definizioneedepidemiologiadott.ssaGreco_file/slide0336.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" P2P slide deck Module ADHD
Il modello del SAS
(Shalli= ce, 1989)
Sistema Attentivo Supervisore
Sistema multicomponenziale che si colloca in diverse aree cerebrali
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