Limited Prosocial Emotions in a Clinical Population of Children and Adolescents: Proposal for Core and Ancillary Characteristics.

OBJECTIVE: Limited prosocial emotions (LPE) has been recently incorporated into international classifications as a specifier for conduct disorder in the DSM-5 and for all disruptive behavioural disorders in the ICD-11. The aims of the current work were to determine (a) the accuracy of each of the characteristics used to assess the LPE specifier and (b) whether the manner in which symptoms group together supports the idea of LPE having core characteristics. METHOD: Trained clinicians conducted interviews and determined LPE characteristics using responses from 74 parent/guardian and child/adolescent participants. RESULTS: The distribution of LPE characteristics among those participants with LPE (n = 13) was compared to those with only one LPE characteristic (n = 11). The proposal of callous lack of empathy (CLE) and shallow deficient affect (SDA) as core characteristics was supported by strong associations with the presence of the LPE specifier, larger specificity, and sensitivity indices than those for unconcerned about performance and lack of remorse or guilt, as well as by a robust aggregation in a latent class analysis. CONCLUSIONS: CLE and SDA could be considered as core characteristics of LPE in children and adolescents.

Effectiveness of a treatment guideline for schizophrenia in adolescents: Lessons from a middle-income country.

INTRODUCTION: Treatment guidelines for schizophrenia represent a standard way to manage patients, especially in countries with limited staff resources. However, they have not been compared on their efficacy with treatment as usual, despite adult studies suggesting they can be more effective. METHODS: Inpatient and outpatient adolescents with schizophrenia were randomly allocated to be either treated according to a guideline-based treatment ( n = 43) or treatment as usual ( n = 44). The effects on symptoms, psychosocial functioning and cognition were compared in a 6-month follow-up. RESULTS: There were no differences between groups in the pharmacological treatment, reduction in symptom severity or cognition. The guideline-based treatment group showed a better functioning at months 3 and 6. CONCLUSION: The guideline-based treatment had a greater effect than the treatment as usual in the psychosocial functioning of adolescent patients ( www.clinicaltrials.gov ; II3/02/0811).

Age differences in the impact of forced swimming test on serotonin transporter levels in lateral septum and dorsal raphe.

BACKGROUND: Forced swimming test (FST) is an animal model which evaluates behavioral despair and the effect of antidepressants such as the selective serotonin reuptake inhibitors; the FST modifies the expression of some receptors related to antidepressant response, but it is not known whether serotonin transporter (SERT), their main target, is affected by this test in animals of different ages. Antidepressant response has shown age-dependent variations which could be associated with SERT expression. The aim of the present study was to analyze changes in the SERT immunoreactivity (SERT-IR) in dorsal raphe and lateral septum of male rats from different age groups with or without behavioral despair induced by their exposure to the FST, since these two structures are related to the expression of this behavior. METHODS: Prepubertal (24 PN), pubertal (40 PN), young adult (3-5 months) and middle-aged (12 months) male rats were assigned to a control group (non-FST) or depressed group (FST, two sessions separated by 24 h). Changes in SERT-IR in dorsal raphe and lateral septum were determined with immunofluorescence. RESULTS: Pubertal and middle-aged rats showed higher levels of immobility behavior compared to prepubertal rats on the FST. SERT-IR showed an age-dependent increase followed by a moderate decrease in middle-aged rats in both structures; a decreased in SERT-IR in lateral septum and dorsal raphe of pubertal rats was observed after the FST. CONCLUSIONS: Age differences were observed in the SERT-IR of structures related to behavioral despair; SERT expression was modified by the FST in lateral septum and dorsal raphe of pubertal rats.

Patient Characteristics Associated With the Need for Long-Term Treatment in a Child Psychiatry Hospital After the Earthquake in Mexico City.

OBJECTIVE: The aim of this study is to determine the demographic and clinical characteristics associated with the need for long-term treatment in a child psychiatry facility. METHOD: Demographic characteristics, diagnosis, source of referral, time elapsed between the earthquake and the request for care, and the treatment prescribed in the baseline assessment were compared between a group of subjects that required long-term treatment (LTT) and a group that was discharged after a brief intervention (D). RESULTS: A total of 171 patients were seen, and 27% of the subjects required LTT. In general, these subjects were younger, referred from highly affected areas, presented a delay in seeking care, and were mainly diagnosed with anxiety and stress-related disorders. CONCLUSIONS: These findings suggest the need for research regarding the design of mental health programs for the early detection of psychopathology after natural disasters in children and adolescents.

Age and sex differences in the impact of the COVID-19 pandemic on mental health and coping mechanisms in Latin American youth.

BACKGROUND: The COVID-19 pandemic has had negative effects on mental health. Understanding sex and age differences in the perception of stressors, the use of coping strategies, and the prevalence of depression and anxiety can lead to detecting at-risk groups. METHODS: A cross-sectional online study surveyed perceived stressors, coping strategies, and the PHQ-9 and GAD-7 rating scales for symptoms of depression and anxiety. The study was open from Spring 2020 to Spring 2021 and was aimed at children, adolescents and young adults of Latin America. RESULTS: The survey was completed by 3965 participants (63.8% females). The sample was divided into children (N = 621, 15.7%), adolescents (N = 1123, 28.3%) and young adults (N = 2021, 56%). Moderate to severe symptoms of depression and anxiety were found in 43.53% and 27%, respectively, being more frequent in females. Children of both sexes showed the lowest scores in rating scales. Adult females reported a higher level of stress in regards to pandemic news, having someone close diagnosed with COVID-19,the possibility of getting sick, academic delays, economic impact, and depression, while female adolescents reported a higher level of stress regarding the lockdown, losing contact with peers and anxiety. In juxtaposition, females also reported a higher frequency of positive coping strategies. A multivariate analysis confirmed the association of several variables with the presence of depression and anxiety. CONCLUSION: A high prevalence of depression and anxiety was found among young people. Specific intervention programs must be created taking into account age and sex differences.

Negative Symptom Domains Are Associated With Verbal Learning in Adolescents With Early Onset Psychosis.

Background: Early-onset psychosis (EOP) is among the leading causes of disease burden in adolescents. Negative symptoms and cognitive deficits predicts poorer functional outcome. A better understanding of the association between negative symptoms and cognitive impairment may inform theories on underlying mechanisms and elucidate targets for development of new treatments. Two domains of negative symptoms have been described in adult patients with schizophrenia: apathy and diminished expression, however, the factorial structure of negative symptoms has not been investigated in EOP. We aimed to explore the factorial structure of negative symptoms and investigate associations between cognitive performance and negative symptom domains in adolescents with EOP. We hypothesized that (1) two negative symptom factors would be identifiable, and that (2) diminished expression would be more strongly associated with cognitive performance, similar to adult psychosis patients. Methods: Adolescent patients with non-affective EOP (n = 169) were included from three cohorts: Youth-TOP, Norway (n = 45), Early-Onset Study, Norway (n = 27) and Adolescent Schizophrenia Study, Mexico (n = 97). An exploratory factor analysis was performed to investigate the underlying structure of negative symptoms (measured with the Positive and Negative Syndrome Scale (PANSS)). Factor-models were further assessed using confirmatory factor analyses. Associations between negative symptom domains and six cognitive domains were assessed using multiple linear regression models controlling for age, sex and cohort. The neurocognitive domains from the MATRICS Consensus Cognitive Battery included: speed of processing, attention, working memory, verbal learning, visual learning, and reasoning and problem solving. Results: The exploratory factor analysis of PANSS negative symptoms suggested retaining only a single factor, but a forced two factor solution corroborated previously described factors of apathy and diminished expression in adult-onset schizophrenia. Results from confirmatory factor analysis indicated a better fit for the two-factor model than for the one-factor model. For both negative symptom domains, negative symptom scores were inversely associated with verbal learning scores. Conclusion: The results support the presence of two domains of negative symptoms in EOP; apathy and diminished expression. Future studies on negative symptoms in EOP should examine putative differential effects of these symptom domains. For both domains, negative symptom scores were significantly inversely associated with verbal learning.

Early Response in Adolescents with Schizophrenia is not Associated with Remission at Six Months.

OBJECTIVE: The objectives of present study were to determine the frequency of early response (ER), defined as a 20% decrease in total baseline PANSS score at three weeks and to compare the rate of symptomatic and functional remission between schizophrenic adolescents with and without ER. METHODS: The sample included 61 patients (65% males) with a mean age of 15 (+ 1.54) y.o., 88.5% on their first episode of psychosis who were evaluated with PANSS and PSP scales y. They were evaluated with PANSS at week three and with PANSS and PSP at month six. RESULTS: Twenty-three patients (37.7%) showed ER. There were no significant differences in the rate of symptomatic or functional remission at month six between responders and non-responders. CONCLUSIONS: Early response to antipsychotic treatment can be observed in adolescent patients, however, it is not associated with remission at six months.

OBJECTIF: Les objectifs de la présente étude étaient de déterminer la fréquence de la réponse précoce (RP), définie comme étant une diminution de 20 % à 3 semaines du score total de départ à l'échelle des syndromes positifs et négatifs (PANSS); et de comparer le taux de rémission symptomatique et fonctionnelle entre les adolescents schizophréniques avec et sans RP. MÉTHODES: L'échantillon comprenait 61 patients (65 % masculins) d'âge moyen de 15 (+ 1,54) ans, dont 88,5 % à leur premier épisode de psychose ont été évalués à l'aide des échelles PANSS et PSP (rendement personnel et social). Ils ont été évalués à l'aide de la PANSS à la 3e semaine et de la PSP à 6 mois. RÉSULTATS: Vingt-trois patients (37,7 %) ont révélé une RP. Il n'y avait pas de différences significatives des taux de rémission symptomatique ou fonctionnelle à 6 mois entre répondants et non-répondants. CONCLUSIONS: Une réponse précoce au traitement antipsychotique peut s'observer chez les patients adolescents, cependant elle n'est pas associée à la rémission à 6 mois.

Cognitive impairment and its improvement after six months in adolescents with schizophrenia.

Studies evaluating the cognitive impairment in schizophrenic adolescents reported a variable course following antipsychotic treatment, with improvement being associated to patients' demographic or clinical characteristics. OBJECTIVES: To examine the cognitive impairments of a Mexican sample of adolescents with schizophrenia using the MATRICS Consensus Cognitive Battery (MCCB) before and after six months of antipsychotic treatment and to determine which demographic or clinical characteristics could be associated to cognitive improvement. METHODS: A sample of 87 Mexican patients was evaluated with the MCCB. Domain scores for three age groups (12-13, 14-15 and 16-17 y.o.) were obtained at baseline, and after 3 and 6 months of treatment. The groups were compared for demographic and clinical variables (sex, school attendance, years of education, being on their first psychotic episode, duration of illness and mean dose of antipsychotic), and a logistic regression analysis was performed to determine which variables predicted larger improvement. RESULTS: The baseline performance showed scores below the standardized mean, with improvement in all domains except for social cognition; female adolescents showed a larger improvement in attention/vigilance and visual learning domains. CONCLUSIONS: We observed cognitive impairments on schizophrenic adolescents, which improved after six months of treatment in almost all domains.

Age onset subtypes of obsessive compulsive disorder: differences in clinical response to treatment with clomipramine.

An open-label, 8-week, follow-up study was designed to compare subjects with child versus adult onset of obsessive compulsive disorder (OCD) on their clinical characteristics and response to a standardized treatment with clomipramine. The study included 15 children and 13 adults with Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnosis of OCD. Children received 50-225 mg/day (3-5 mg/kg day) and adults 150-250 mg/ day of clomipramine. The children's group had a higher number of males and increased comorbidity than the adults' group. A similar dose/kg day of clomipramine was effective in reducing OCD severity and improving the psychosocial functioning in both groups; however, total improvement according to the National Institute of Mental Health-Global Obsessive Compulsive Rating Scale (NIMH-GOCRS) was greater in adults. Adults reported a higher frequency of side effects compared to children, with dry mouth and constipation more common at the end of the study. These data suggest that children with OCD seeking treatment may have differences from adults and support the importance of studying age-of-onset subtypes of OCD.

Amoxapine as an atypical antipsychotic: a comparative study vs risperidone.

Amoxapine is marketed as an antidepressant. However, its in-vitro profile, receptor occupancy and preclinical effects are very similar to atypical antipsychotics. Amoxapine has also shown efficacy as an atypical antipsychotic in open trials. The objective of this study was to compare the antipsychotic and side effect profile of amoxapine and risperidone in a randomised assignment, standardized dosing, double-blind trial of acutely psychotic patients with schizophrenia. A total of 48 schizophrenic patients were enrolled and randomized in a double-blind 6-week trial to receive either risperidone (up to 5 mg/day) or amoxapine (up to 250 mg/day). Positive, negative, affective symptoms and motor side effects were measured using standardized weekly assessments. Prolactin levels were also determined at baseline and at the end of the study. A total of 39 patients (amoxapine, n=22; risperidone, n=21) completed the trial. Both pharmacological treatments, amoxapine 228.0 mg/day (SD=34.6) and risperidone 4.5 mg/day (SD=0.7), showed equivalent improvement in positive, negative, and depressive symptoms. Amoxapine was associated with less EPS and less prolactin elevation than risperidone. These data support previous reports about the efficacy of amoxapine as an atypical antipsychotic. Since amoxapine is off-patent, it may be a valuable low-cost alternative to new atypical antipsychotics, particularly in low-income countries where the majority of the patients are still treated with typical antipsychotics.

Validity and reliability of the Spanish version of the Personal and Social Performance scale in adolescents with schizophrenia.

BACKGROUND: The Personal and Social Performance (PSP) scale is a widely used tool to evaluate adults with schizophrenia; however, more studies are needed regarding its usefulness in the assessment of adolescent patients, since the evaluation of their functioning could require adaptations according to development. OBJECTIVE: To examine construct validity, convergent validity, internal consistency and interrater reliability of the PSP in a sample of Mexican adolescents with schizophrenia. METHODS: A total of 40 patients with a DSM-IV diagnosis of schizophrenia or schizophreniform disorder were evaluated with PSP, CGAS, PANSS and the MATRICS battery. Construct and convergent validity were determined by the correlation between PSP with PANSS factors, MATRICS dimensions and CGAS. In addition, reliability was evaluated with Cronbach's alpha and intraclass correlation coefficients. RESULTS: PSP scores correlated with negative, excitement and cognitive factors of PANSS, CGAS as well as MATRICS domains. The PSP also showed high internal consistency and interrater reliability. CONCLUSIONS: The PSP is a valid and reliable instrument for the assessment of adolescent patients.

Sex differences on spontaneous alternation in prepubertal rats: implications for an animal model of obsessive-compulsive disorder.

UNLABELLED: Sex differences in the prevalence of obsessive-compulsive disorder (OCD) in prepubertal children have been described. Deficits on spontaneous alternation behavior (SAB) have been proposed as an animal model of OCD. OBJECTIVES: To explore possible sex differences in the ontogeny of SAB and in the effect of the 5-HT1A agonist, 8-OH-hydroxy-2 (di-n-propylamino)-tetralin (8-OH-DPAT) in an animal model of OCD. METHODS: The ontogeny of SAB and the perseveration produced by 8-OH-DPAT were compared between male and female prepubertal rats. RESULTS: Males alternated their arm choose from postnatal day 32 onwards, while females perseverated in the chosen arm until postnatal day 38. The mean number of repetitive choices remained close to 1 in males from postnatal day 23 onwards, but females showed a mean number of repetitive choices higher than 1.5 until the end of the test. The 8-OH-DPAT (0.125, 0.5 and 2.0 mg/kg, 15 min) produced perseveration in males but not in females. CONCLUSIONS: These data show important sex differences in the ontogeny of SAB and the effect of 8-OH-DPAT in a model of OCD. Such differences could be relevant for the sex differences in the prevalence of childhood OCD.

Age differences in an animal model of obsessive-compulsive disorder: participation of dopamine: dopamine in an animal model of OCD.

The putative age difference in the effect of chronically administered quinpirole (0.125 and 0.5 mg/kg, 11 injections) on alternation in a T maze was studied. Male juvenile (43 days old) and adult (around 90 days old) rats exhibited similar control values of alternation. In adults, quinpirole (0.5 mg/kg) produced a drastic perseveration after 10 and 11 injections (mean number of repetitive choices of 3.4 and 3.1, respectively); conversely, in juvenile, such treatment produced a less marked perseveration (mean number of repetitive choices of 1.7 and 2.1, for the 10th and 11th injection, respectively). We also studied the age difference in the protective actions of clomipramine subchronically administered (15 mg/kg, three times) on the quinpirole-induced perseveration. Clearly, as previously demonstrated, in adult animals, this tricyclic antidepressant completely prevented the drug-induced perseveration (mean number of repetitive choices of 1.7); while in juvenile, animals only produced a weak action (mean number of repetitive choices of 1.8). Data agreed with basic research showing a hyposensitivity of juvenile animals to dopaminergic agonists and with clinical findings suggesting a weaker effect of clomipramine treatment in youth. These results reinforce perseveration in a T maze as a useful animal model for studying age differences in obsessive-compulsive disorder (OCD).

Survey on schizophrenia treatment in Mexico: perception and antipsychotic prescription patterns.

BACKGROUND: Since the introduction of antipsychotics, especially the so called atypicals, the treatment of schizophrenia has shown important improvements. At the present time, it is preferred to label clozapine and other antipsychotics sharing similar profiles as second-generation antipsychotics (SGAs). These medications have been proposed by some experts as a first line treatment for schizophrenia. It is critical to have reliable data about antipsychotic prescription in Mexico and to create management guidelines based on expert meetings and not only on studies carried out by the pharmaceutical industry. Only this approach will help to make the right decisions for the treatment of schizophrenia. METHODS: A translated version of Rabinowitz's survey was used to evaluate antipsychotic prescription preferences and patterns in Mexican psychiatrists. The survey questionnaire was sent by mail to 200 psychiatrists from public institutions and private practice in Mexico City and Guadalajara, Mexico. RESULTS: Recommendations for antipsychotics daily doses at different stages of the treatment of schizophrenia varied widely. Haloperidol was considered as the first choice for the treatment of positive symptoms. On the contrary, risperidone was the first option for negative symptoms. For a patient with a high susceptibility for developing extrapyramidal symptoms (EPS), risperidone was the first choice. It was also considered that SGAs had advantages over typical antipsychotics in the management of negative symptoms, cognitive impairment and fewer EPS.Besides, there was a clear tendency for prescribing typical antipsychotics at higher doses than recommended and inadequate doses for the atypical ones. CONCLUSIONS: Some of the obstacles for the prescription of SGAs include their high cost, deficient knowledge about their indications and dosage, the perception of their being less efficient for the treatment of positive symptoms and the resistance of some Mexican physicians to change their prescription pattern. It is necessary to reach a consensus, in order to establish and standardize the treatment of schizophrenia, based on the information reported in clinical trials and prevailing economic conditions in Mexico.

Out of the office and into the field: Exploring neuropsychological correlates between search behavior and a traditional desktop task in children and adolescents with ADHD / Del consultorio a la vida cotidiana: Una exploración de los correlatos neuropsicológicos entre una prueba tradicional de escritorio y de la conducta de búsqueda en niños y adolescentes con TDAH

Abstract Introduction Cognitive assessment of patients with attention deficit hyperactivity disorder (ADHD) can help clinicians provide individually tailored treatment and advice, and researchers to identify potential associations between psychopathology and specific cognitive deficits. Assessment instruments, however, have received some criticism regarding their ecological validity, that is, the capacity to extrapolate from the performance on such tasks to aspects of everyday functioning. In order to meet this challenge we developed the Ball Search Field Task (BSFT) that takes place outdoors and uses large, open areas. In the BSFT, the goal is to search for target objects hidden under opaque containers, with experimenters assessing the efficiency of participants' strategies to collect a maximum of these. Objective Here we explore how the measures produced by one of the latest versions of this task (the patchy BSFT) match up with a traditional desktop task often used in clinical environments, the Tower of London (ToLo). Method We applied the BSFT and ToLo to children and adolescents with ADHD and compared the metrics using Spearman correlations. Results We found significant, moderate correlations between instruments, as exemplified by that of balls collected per cones lifted (BSFT) and number of moves (ToLo) (r = -.44). Discussion and conclusion Matching correlates between the BSFT and ToLo suggest these tasks may be tapping into similar cognitive processes. The addition of assessment tools with ecological validity may help provide a more comprehensive evaluation and a better understanding of the day-to-day impact of cognitive afflictions underlying psychiatric disorders such as ADHD.

Resumen Introducción La evaluación cognitiva de pacientes con déficit de atención e hiperactividad (TDAH) puede ayudar al personal clínico a personalizar el tratamiento y a los investigadores a identificar asociaciones entre psicopatología y deficitarios cognitivos específicos. Los instrumentos de evaluación han recibido críticas en cuanto a su validez ecológica, esto es, la capacidad de extrapolar el desempeño en dichos instrumentos a situaciones de la vida diaria. Con este desafío en mente, desarrollamos la Prueba de Búsqueda de Pelotas (BSFT, por sus siglas en inglés) que se lleva a cabo en áreas abiertas y amplias. La BSFT consiste en buscar objetos escondidos bajo contenedores opacos para evaluar la eficiencia de la búsqueda que intenta encontrar el mayor número posible de objetos. Objetivo Exploramos la manera en que una versión de esta tarea (la BSFT en parches) se compara con una tarea de uso común en ambientes clínicos, la Torre de Londres (ToLo, por sus siglas en inglés). Método Aplicamos la BSFT y la ToLo a niños y adolescentes con TDAH y comparamos las métricas resultantes mediante una correlación de Spearman. Resultados Encontramos correlaciones significativas entre estas pruebas, como lo ejemplifica aquella entre el número de conos levantados (BSFT) y el número de secuencias correctas (ToLo) (r = -.48). Discusión y conclusión Correlatos de equivalencia entre la BSFT y la ToLo sugieren que estas tareas demandan procesos cognitivos similares. Investigar tareas con validez ecológica puede ayudarnos a ofrecer una evaluación más completa y a entender mejor el impacto diario de las afectaciones cognitivas subyacentes a trastornos psiquiátricos como el TDAH.

Sex and age differences in the impact of the forced swimming test on the levels of steroid hormones.

Compared with the adult disorder, depression in children exhibits differences in its neurobiology, particularly in the HPA axis regulation. The bases of such differences can be evaluated in animal models of depression. The objective of the present study was to determine age and sex differences of Wistar rats in the forced swimming test (FST). The influence of sex and age on corticosterone, estrogens and testosterone serum levels was also determined. Prepubertal rats showed immobility, swimming and climbing behaviors during the pre-test and test sessions. In addition, in the prepubertal animals, no sex differences were found during the pre-test and test sessions. Age comparisons indicated no differences in the female groups, however adult males exhibited more immobility and less swimming than young males, in both FST sessions. The young and female rats showed less immobility behavior and increased levels of estrogens after the FST. The present results indicate that the FST is an animal model suitable to evaluate depressive-like behaviors in prepubertal subjects and to explore behavioral changes related to neurodevelopment.

Conocimientos, creencias y actitudes en padres mexicanos acerca del trastorno por déficit de atención con hiperactividad (TDAH) / Knowledge and beliefs in Mexican parents about attention deficit hyperactivity disorder (ADHD)

Attention deficit hyperactivity disorder (ADHD) generates controversy among the general population on its diagnosis and treatment. This could be explained by the sparse level of education about mental health, which affects the parent's knowledge and beliefs about this disorder. ADHD is highly prevalent and 3-5% of school-age children can be diagnosed. In Mexico it represents 1.5 million cases. It represents more than 30% of all cases in clinical pediatric settings. The reports in health services have shown that the time gap between symptoms identification and treatment is around 8 to 15 years. Moreover, only 25% of the affected children's parents recognize conduct or emotional problems on them and 13% receive mental health care. Attention seeking has been associated with higher severity of the disorder and parent's superior educational level. Despite the advances in the research on neurobiology and psychopharmacology, understanding of the social context that surrounds the disorder is incomplete. Comparatively little is known regarding how parents conceive the symptoms and causes of ADHD and how these parental views may relate to children's treatment. Understanding these factors is important due to the central role of parents in selecting and accessing treatments and service providers for children with ADHD. For parents and children, getting information about ADHD is a lottery that depends on which professional they see and what they read or gather from television and the Internet. Mental health professionals most give complete information to parents and children, so risks and benefits of the different treatments may be considered along with the family's needs, values and cultural background. A better understanding about the parent's knowledge, beliefs and attitudes regarding ADHD would help to improve the communication mechanisms between mental health professionals and parents during the treatment. Objective To describe the knowledge, beliefs and attitudes regarding ADHD in Mexican parents. Methods The study was approved by the local investigation review board. Informed consent was obtained and parents of children and adolescents diagnosed with ADHD were recruited at four mental health facilities (three public and one private) in two cities. Each parent completed the questionnaire of knowledge and beliefs about ADHD (CASE ADHD, parent's version). The questionnaire was created for this study as an instrument with three versions: a) Parents, b) Teachers, c) Health professionals. Results of parent's version were included in this report. This questionnaire incorporates information of other instruments such as Barkley's Evaluation Questionnaire and the one used in the National Colombian Survey for the Consensus of treatment of ADHD 2008. CASE ADHD includes three parts: 1. An identification record with the mother's or father's general data, 2. The ADHD Rating Scale-IV, and 3. A 36 multiple choice questionnaire related to six main areas: a) The caretaker report of symptoms and clinical characteristics related with ADHD, b) The knowledge about ADHD, c) The pathways to care report, d) The Beliefs about ADHD treatment, e) The professional mental health's performance, and f) The parent's perceptions about ADHD. The questionnaire must be completed with the assistance of a mental health professional. The average application time is 30 minutes. For statistical analysis central tendency measures were used; as means, standard deviations and percentages. Results The total sample was integrated by 288 parents of children or adolescents. The 80.1% of the questionnaires were fulfilled by the mother. The mean age of those who answered was 40.06 years, 25.4% reported to complete professional studies. The mean age of patients was 11.15 years (SD = 3.54), 58% were children and 74% were male, their ADHDRS-IV average score was 27.5 (SD = 14.03). Knowledge about ADHD. The 85.4% (N = 246) of the surveyed sample considered ADHD as a disease and 8.3% as a rearing difficulty. The 69.2% (N = 198) of parents said they knew what is ADHD, but only 62.1% reported to receive information by the physician or psychologist about this condition. Attitudes about ADHD. When questioned about what would they do if they suspected that their child had ADHD, 35.1 % (N = 101) would consult a psychiatrist, 21.2% a psychologist, and 12.2% a neurologist or pediatric neurologist. The 28% of parents were deemed unable to manage their child's behavior problem. When we asked about who is able to diagnose ADHD, 49.5% answered that the psychologist, 48.5% the psychiatrist and 19.8% that the pediatrician. The psychiatrist was considered able to treat this condition by 45.8% of the sample followed by psychologist (19.8%), and neurologist (10.4%). Beliefs about diagnosis and treatment. Nearly 63% of the sample (N = 183) considered that the best treatment for ADHD was the combined treatment; 16.3% preferred the psychological approach and psychopharmacology was chosen by only 6.6%. Almost half (48.5%, N= 129) of the sample considered that drug treatment only supports the psychosocial treatment and does not have a therapeutic effect by itself, 46.2% (N = 133) of the sample believed that <

Introducción A pesar de la evidencia científica acerca de las características neurobiológicas del Trastorno por Déficit de Atención e Hiperactividad (TDAH) que apoya el uso de medicamentos para su tratamiento, este padecimiento sigue generando controversia con respecto a su existencia, su persistencia a lo largo de la vida y su tratamiento óptimo. La prevalencia del TDAH a nivel mundial es alta. Los estudios epidemiológicos muestran que 3 a 5% de los niños en edad escolar pueden recibir este diagnóstico. En México se estima que hay aproximadamente 33 millones de niños y adolescentes, de los cuales 1.5 millones podrían ser diagnosticados con TDAH. En el contexto clínico, al menos 30% de los pacientes que acuden a valoración de primera vez en los servicios de psiquiatría infantil presentan problemas de inatención, hiperactividad o impulsividad. Algunos estudios epidemiológicos han mostrado que sólo el 25% de los padres de sujetos con síntomas de trastornos de conducta o del afecto consideraban que sus hijos necesitaban atención médica, y de ellos, el 13% acudió a los servicios de salud mental. La búsqueda de atención especializada se ha asociado con una mayor intensidad del trastorno y un mayor nivel educativo de los padres. Diversas publicaciones relacionadas con el tratamiento del TDAH a lo largo de la vida resaltan la importancia de la intervención multimodal, es decir, un tratamiento multidisciplinario que va más acorde al modelo biopsicosocial el cual, a su vez, se encuentra relacionado con los factores etiológicos y de pronóstico a mediano y largo plazo en el TDAH. En diversos estudios se ha subrayado la importancia de brindar educación adecuada sobre el trastorno y su tratamiento. También sugieren que un mejor entendimiento acerca de las creencias y conocimientos de los padres de niños y adolescentes con TDAH ayudará a mejorar los mecanismos de comunicación, atención y colaboración entre los distintos elementos participantes en el tratamiento del TDAH y reducirá el tiempo entre la identificación del problema y el inicio del tratamiento. Objetivo Describir los conocimientos, las creencias y actitudes de los padres de niños y adolescentes con TDAH acerca de la naturaleza de la enfermedad, la conducta en la búsqueda de atención médica y su tratamiento. Material y métodos La muestra fue conformada por padres de niños y adolescentes que habían recibido el diagnóstico de TDAH por un clínico calificado. Participaron cuatro centros de atención psiquiátrica, tres en la Ciudad de México y otro en la ciudad de San Luis Potosí. El instrumento principal (CASO ADH padres) es un cuestionario autoaplicable y fue escrito específicamente para este estudio. CASO ADHD es un instrumento con tres versiones: a) Padres, b) Maestros y c) Profesionales de la salud. En este estudio se exponen los resultados de la primera versión. Resultados La muestra total se conformó de 288 padres. El 69.2% dijo saber qué es el TDAH, 85.4% consideró al TDAH como una enfermedad y el 8.3% como una dificultad de la crianza; el resto lo consideró un mito, una moda, un invento de la industria farmacéutica o no existente. Alrededor del 63% de la muestra consideró que el mejor tratamiento para el TDAH sería el tratamiento combinado, el 16.3% prefirió el enfoque psicológico y sólo 6.6% eligió la psicofarmacología. Casi la mitad de la muestra, 48.5%, consideró que el tratamiento farmacológico solamente apoya al tratamiento psicosocial. La mayoría de los padres (60%) identificaron los síntomas de sus hijos en su propia conducta durante los años escolares. Conclusiones Es importante mejorar la cantidad y la calidad de educación acerca del TDAH y su tratamiento entre los padres de los pacientes, para que sus decisiones terapéuticas sean más informadas y tengan mejor efecto sobre el pronóstico del paciente.

Minimum effective doses of haloperidol for the treatment of first psychotic episode: a comparative study with risperidone and olanzapine.

Minimum doses of haloperidol might show similar efficacy and side-effects compared to atypical antipsychotics. The objectives of this study were to compare the efficacy of minimum doses of haloperidol with standard doses of risperidone and olanzapine on a 6-month open trial in first psychotic episode patients and to examine the effect of compliance on their outcome. Forty-two patients were recruited and started on flexible doses of these drugs. Olanzapine was given with no cost to the patients. Efficacy and side-effects were monitored every 3 months using standardized assessments. Thirty patients completed the study. All treatment groups showed improvement in positive, negative and depressive symptoms. There were no differences in side-effects among them. The haloperidol group required higher doses of anticholinergics. The rate of treatment discontinuation was higher in the risperidone group due to the direct cost. Minimum doses of haloperidol might prove to be a good choice of treatment for patients with a first episode of psychosis.

Algoritmo del tratamiento para el trastorno por déficit de atención con hiperactividad en niños y adolescentes

resumen está disponible en el texto completo

Summary The diagnostic criteria for the Attention Deficit Hyperactivity Disorder (ADHD) have been changing according to international classifications. It is currently included in the ICD-10 as an hyperkinetic disorder and in the DSM-IV as a disorder having its onset during childhood and adolescence. The reported prevalence for ADHD is between 3% and 6%; up to 60% of the patients remain symptomatic through adolescence and adulthood. Population-based surveys of physicians who treat children and adolescents reveal that the rate and the proportion of office visits associated with ADHD are high and have increased over the past decade. This fact points to the need of elaborating clinical guidelines for the treatment of this disorder. Evidence from controlled clinical trials confirms the superiority of medication management for ADHD over behavioral therapy and the combination of medication and behavioral treatment. Stimulants are the most studied drugs for ADHD and constitute the first treatment of choice. Methylphenidate (MPH) is the only stimulant available in Mexico. Its mechanism of action is based on the blocking of the dopamine reuptake, which increases the availability of this neurotransmitter in the synaptic cleft. Based on the dopaminergic theories of ADHD, dopamine genes have been the initial candidates for molecular studies regarding response to MPH. Variations of the dopamine D4 receptor gene (DRD4) and the dopamine transporter gene (DAT1) have been related with the response to MPH. The short half life of this drug (less than three hours) supports the shift from once-a-day to twice-a-day or thrice-a-day dosing. The Osmotic Release Oral System (OROS) of MPH allows to maintain therapeutic plasmatic doses with once-a-day dose. Its efficacy and tolerability have been shown in clinical trials. Regarding the long-term effects of MPH, this drug has demonstrated efficacy in a two-year follow-up controlled study. In addition, animal models have shown that the chronic exposure to MPH during developmental periods produces changes in the function of brain dopaminergic cells, as well as changes in behavior. The association between MPH and substance abuse has also been explored. The pharmacokinetic and pharmacodinamic differences between MPH and cocaine, which also acts by blocking the dopamine transporter, were examined: When administered intravenously, MPH, like cocaine, has a reinforcing effects at doses that exceed a 60% dopamine transporter blockade threshold. When administered orally at clinical doses, the pharmacological effects of MPH also exceed this threshold, but reinforcing effects rarely occur. So, the pharmacokinetic properties of MPH in brain differ for oral and intravenous routes of administration, suggesting that the oral administration of MPH mimics the tonic dopamine cell firing, which may be a critical factor associated with clinical effects. In addition, therapeutic doses of MPH do not act at the nucleus accumbens, a brain structure highly associated with reinforcing. These data suggest that oral administration of MPH does not lead to abuse. Follow-up studies have also shown that stimulant therapy is not associated with increased risk of substance abuse. Since 30% of the patients do not respond to stimulant treatment, the efficacy and safety of other drugs have been evaluated. Among them, tricyclic antidepressants (TCAs) are considered a good choice for the management of ADHD and conduct disorders. Their half life is longer than that of MPH, which allows a once-a-day or twice-a-day dosing. It has also been described that TCAs are effective for the treatment of comorbid tics. The main disadvantage of these drugs is their effect on cardiac conduction, which has been associated with sudden death. Bupropion is another antidepressant having an effect on dopamine activity. It has shown efficacy for the treatment of ADHD in children, adolescents, and adults, particularly in patients with nicotine dependence, patients with comorbid conduct disorder, or depression. Bupropion is available in a extended-release, once-daily formulation (XL). The main side effects of this antidepressant are the increased risk of seizure development, rash and mild elevation of blood pressure. This drug is not recommended for the treatment of patients with comorbid eating disorders. Venlafaxine (a serotonin and norepinephrine reuptake inhibitor) and reboxetine (a norepinephrine reuptake inhibitor) are recently introduced antidepressants which have shown efficacy in open label trials on patients with and without comorbid depressive disorder. Atomoxetine is another non-stimulant medication; its main mechanism of action is the inhibition or the reuptake of norepinephrine. Several clinical trials have shown its efficacy for the treatment of ADHD in children, adolescents and adults. This drug can also be administered in a single dose; in addition, it has a low potential for cardiotoxicity and a reduction of tic frequency and severity has been reported with its use. It is also recommended for the ADHD comorbid with anxiety or depression. Nausea and decreased appetite are the most common side effects of atomoxetine. Modafinil is another non-stimulant drug which was initially described for the treatment of narcolepsy. This drug increases the dopamine and norepinephrine activity through its direct effect on glutamate and GABA, among other neuromodulators. Some clinical trials have shown its superiority over placebo on ADHD symptoms. The main side effects of modafinil are gastrointestinal distress and insomnia. Clonidine and risperidone are drugs considered as second treatment of choice or adjunctive treatments for patients with comorbidity. Although medication is the first treatment of choice, patients often get benefits from psychosocial interventions, particularly parent training in contingency management methods and classroom applications of contingency management techniques. The value of these measurements lies in the temporary reduction of symptom levels and/or in the reduction of related behavioral and emotional difficulties, such as defiance and conduct problems, depression, low self-esteem, or academic underachievement. Parents' training focus on general contingency management tactics, such as contingent application of reinforcement or punishment following appropriate/inappropriate behaviors. Reinforcement procedures have typically relied on praise or tokens, while punishment methods have usually been the loss of tokens or time-out from reinforcement. The classroom management include a continuous communication with teachers, in order to maintain them informed about the illness and its treatment, as well as training on contingency management tactics. The aforementioned information was used in the elaboration of clinical guidelines for the treatment of youngsters with ADHD, either alone or comorbid with internalizing or externalizing disorders. Another guideline for the management of preschool children with ADHD is included. Psychoeducation follows the assessment of the children in each case. The pharmacological treatment recommendations give priority to monotherapy. Stimulants are the first treatment of choice in each guideline. The use of non-stimulant medications as second choice will depend on the age and comorbidity of patients.