Milano, 28 maggio 2013

Cristiano Termine UONPIA Ospedale di Circolo, Fondazione Macchi di Varese

Milano, 28 maggio 2013

Azienda Ospedaliera

SPEDALI CIVILI BRESCIA

ADHD: per una condivisione dei percorsi

diagnostico-terapeutici

DAL REGISTRO REGIONALE

SESSIONE: COMORBIDITÀ

COMPLETATA

492

Riepilogo inserimento dei pazienti

GIA’ IN

CARICO

79

NUOVI

ACCESSI

597

DIAGNOSI

INSERITI

676

VALUTAZIONE

NON COMPLETATA

86

USCITI

19

ADHD

326

NO ADHD

166

Numero comorbidità

Registro Regionale Jensen et al., 2001 MTA Study

Almeno 1 comorbidità 57% 70%

2 o più comorbidità 13% 40-50%

44,2

43,3

10,1

2,1 0,3

Registro regionale

Disturbi psichici N %

Disturbi dell'apprendimento 120 37

Disturbo oppositivo – provocatorio 38 12

Ansia 27 8

Disturbi dell’umore 6 2

Disturbi della condotta 5 2

Disturbi da tic / Sindrome di Tourette 7 2

Ritardo mentale 11 3

Disturbi dello spettro autistico 2 1

Dati

Internazionali

%

46

40

34

4

14

11

13

6

Tipo di comorbidità

DSM- I -> DSM-5

(1)

(2)

(3)

Registro regionale




Ansia 27 8






Dati

Internazionali

%

46

40

34

4

14

11

13

6


Depistaggio sistematico

Italia USA

3.6% 7.3%

Lindgren, De Renzi and Richman (1985)

Cross-national comparisons of developmental dyslexia in Italy and the United States.

Child Dev. 1985; 56:1404–1417.

Prevalenza della dislessia

Possible Locations of Genes That Influence

RD, ADHD, or both RD and ADHD

RD

R+A

R+A

RD

RD

RD RD

RD

R+A

RD

AD R+A

AD

AD

AD

R+A R+A

AD

R+A

R+A

RD

RD RD R+A

AD

ADHD / DSA

Eziopatogenesi comune Modello eziologico probabilistico e

multifattoriale (Pennington 2006)

Measures

Latent Variable Measures Used to Predict Latent Variable

_____________________________________________________________________________

Reading Ability Time limited word recognition task, PIAT Reading Recognition,

& PIAT Spelling

Inattention Symptoms Mother, Father, Teacher, & Examiner Ratings

Hyperactive/Impulsive

Symptoms Mother, Father, Teacher, & Examiner Ratings

PA Phoneme Deletion (% correct, blocks 1 & 2), Pig Latin test, & the

Lindamood Auditory Conceptualization task

VR Information, Similarities, Vocabulary, & Comprehension from

the WISC-R

WM Nonword Repetition, Digit Span (Forward & Backward), Sentence Span &

Counting Span

Inhibition Gordon Diagnostic System commission errors (Vigilance &

Distractibility), & Stop Signal Reaction Time from the Stop Task

PS WISC-R Coding, WISC-III Symbol Search, Colorado Perceptual Speed

Task,Identical Pictures, Trailmaking Test, Rapid Automatized Naming

Task (Colors, Numbers, Letters, & Pictures) & Stroop Task (Word Naming

& Color Naming)

_____________________________________________________________________________________ Note. For ADHD, mean severity ratings from each rater were used as the indicators. This strategy allows for more variance than the more typical

strategy of defining ADHD using symptom counts.

Note. Errors from the same instrument (e.g., WISC Coding and Symbol Search) were allowed to correlate in both measurement models.

Results

Measurement Model

The best fitting measurement model was one which created separate latent variables for the continuous symptoms of inattention

and symptoms of hyperactivity/impulsivity (χ2 /df= 2.303, CFI= 0.986, RMSEA=0.045).

The measurement model for the latent variables of the the cognitive constructs was also a good fitting model (χ2 /df= 3.187, CFI=

0.915, RMSEA=0.059).

Full SEM Model

The full SEM model was also a good fit (χ2 /df= 2.63, CFI= 0.918, RMSEA=0.05

PA

VR

WM

PS

Inhibition

Reading

Ability

Symptoms off

Inattention

Symptoms

of Hyperactivity/

Impulsivity

0.33**

0.28**

0.59*

-0.28*

0.46*

0.44**

Registro regionale




Ansia 27 8






Dati

Internazionali

%

46

40

34

4

14

11

13

6


Mancato depistaggio

Disturbo evolutivo della coordinazione motoria ? ? 40

J Child Psychol Psychiatry. 2001 May;42(4):487-92. The comorbidity of ADHD in the general population of Swedish school-age children. Kadesjö B, Gillberg C. Source Göteborg University, Sweden. Abstract This study examined patterns of comorbid/associated diagnoses and associated problems in a population sample of children with and without DSM-III-R attention-deficit hyperactivity disorder (ADHD). Half (N = 409) of a mainstream school population of Swedish 7-year-olds were clinically examined, and parents and teachers were interviewed and completed questionnaires. The children were followed up 2-4 years later. Eighty-seven per cent of children meeting full criteria for ADHD (N = 15) had one or more and 67% at least two--comorbid diagnoses. The most common comorbidities were oppositional defiant disorder and developmental coordination disorder. Children with subthreshold ADHD (N = 42) also had very high rates of comorbid diagnoses (71% and 36%), whereas those without ADHD (N = 352) had much lower rates (17% and 3%). The rate of associated school adjustment, learning, and behaviour problems at follow-up was very high in the ADHD groups. We concluded that pure ADHD is rare even in a general population sample. Thus, studies reporting on ADHD cases without comorbidity probably refer to highly atypical samples. By and large, such studies cannot inform rational clinical decisions.

ADHD and developmental coordination disorder (DCD) are two developmental conditions that may cause motor, academic and social

dysfunctions (APA, 1994). Their coexistence was documented in several studies, and as many as 35–47%

of the children with ADHD were diagnosed as having comorbid DCD.

http://www.ncbi.nlm.nih.gov/pubmed/11383964%23

http://www.ncbi.nlm.nih.gov/pubmed?term=Kadesj%C3%B6%20B%5BAuthor%5D&cauthor=true&cauthor_uid=11383964

http://www.ncbi.nlm.nih.gov/pubmed?term=Gillberg%20C%5BAuthor%5D&cauthor=true&cauthor_uid=11383964

(1)

(2)

(3)

Registro regionale




Ansia 27 8






Dati

Internazionali

%

46

40

34

4

14

11

13

6


ADHD

326

CON KSADS

259

SENZA KSADS

67

Sintomi Sottosoglia Patologici Disturbo oppositivo-provocatorio 19 18

Ansia 9 4

Disturbi depressivi 8 5

Disturbo della condotta 7 1

Disturbo di ansia da separazione 6 2

Enuresi 2 1

Episodio maniacale 1 1

Disturbo da tic 1 3

Fobie 0 4

Disturbo psicotico 0 0

Disturbo di panico 0 0

Disturbo di fobia sociale 0 0

Disturbo ossessivo-compulsivo 0 0

Encopresi 0 0

Anoressia nervosa 0 0

Bulimia nervosa 0 0

Abuso di alcol 0 0

Abuso di sostanze 0 0

Disturbo post-traumatico da stress 0 0

Comorbidità KSADS

Dist.

Condotta

Tic

Tourette Autismo

Dist.

Apprendimento

Dist.

dell’Umore

ADHD

Dist.

d’Ansia

DIAGNOSI DIFFERENZIALE e

COMORBIDITÀ

DOP

DCD

Registro regionale




Ansia 27 8






Dati

Internazionali

%

46

40

34

4

14

11

13

6


TOURETTE’S SYNDROME - SPECTRUM

Tics

OCD

Behavioral problems

ADHD

TS

Tourette’s Syndrome-Plus

Full-Blown Tourette’s Syndrome

Pure Tourette’s Syndrome

Chronic Tic Disorders

Phenotipic heterochronya Leckman 2002

COEXISTING CONDITIONS MAY INTERFERE WITH THE TREATMENT

ESSTS Annual Meeting 2013 COST International Conference for Tourette

Syndrome

The frequency and reason for pharmacological treatment in a Danish clinical cohort of 314 children with Tourette syndrome. In total, 60.5% of the children once had received pharmacological treatment.


Syndrome


Syndrome

Treatment of comorbidities: ADHD


Syndrome

Rizzo et al., 2013

(1)

(2)

(3)

Registro regionale




Ansia 27 8






Dati

Internazionali

%

46

40

34

4

14

11

13

6


COMORBIDITY:

the coexistence of two conditions

within a single individual (Feinstein, 1970)

- Current (at the time of study)

- Lifetime (over the course of an individual’s life)

Phenotypical heterochronia

varying expression of comorbidity over time (Nappi et al. 2000)

Milano, 28 maggio 2013

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