Os transtornos do comportamento disruptivo (TDC), representados pelo transtorno de oposição desafiante e pelo transtorno de conduta, e o transtorno de déficit de atenção/hiperatividade (TDAH) são transtornos intimamente relacionados. Teorias e estudos sugerem o envolvimento de regiões relacionadas ao processamento de emoções e de recompensas, entre elas a amígdala e o núcleo accumbens (NAcc), em ambos os transtornos. Avaliar as conexões cerebrais do NAcc e da amígdala nos TCD e no TDAH pode contribuir para a elucidação da neurobiologia dos transtornos e de comportamentos relacionados. O objetivo do presente estudo foi caracterizar a conectividade funcional do NAcc e da amígdala em crianças com TDAH e com TCD e avaliar a relação entre a conectividade funcional destas regiões e comportamentos atípicos característicos e comuns a ambos os transtornos. Neste estudo, crianças (idade média = 11,28 anos) classificadas como apresentando TCD (n=22), TDAH (n=25) ou desenvolvimento típico (DT; n=236) foram submetidas a sessão de ressonância magnética funcional de repouso. Foi avaliada a conectividade funcional de repouso de 2 regiões de interesse (NAcc e amígdala) ao restante do cérebro. Em uma abordagem categórica, os mapas de conectividade foram comparados entre os grupos. Além disto, em uma abordagem dimensional, conectividade funcional do NAcc e da amígdala foi correlacionada a pontuações em 3 dimensões de comportamento: desatenção/hiperatividade, agressividade e problemas de conduta, gerando 3 mapas de correlação (conectividade x comportamento) para cada região. Nesta etapa toda a amostra foi incluída (n=283). Os resultados da abordagem categórica mostraram algumas conexões específicas do TCD e do TDAH. As conexões do NAcc à insula posterior e ao precuneus diferenciaram os TCD do DT e do TDAH. A conexão entre amígdala e giro lingual diferenciou TDAH de DT e de TCD. O TDAH também exibiu conectividade atípica da amígadala com o giro pré-central e com o lóbulo parietal inferior, comparado a crianças com DT. Não foi encontrada conectividade funcional alterada do NAcc em crianças com TDAH ou da amígdala em crianças com TCD, comparadas a crianças com DT. A abordagem dimensional demonstrou um padrão diferente de resultados. Pontuações de desatenção/hiperatividade e agressividade estiveram associadas a conectividade do NAcc ao giro fusiforme e ao córtex pré-frontal dorso-medial. Desatenção/ hiperatividade esteve correlacionada com conectividade da amígdala ao lóbulo parietal inferior, ao giro temporal médio e ao sulco pré-central superior. Agressividade esteve correlacionada com conectividade da amígdala ao precuneus e ao giro frontal superior. Problemas de conduta estiveram correlacionados com a conectividade NAcc-giro frontal superior e com a conectividade da amígdala ao giro cingulado posterior, ao precuneus, ao córtex pré-frontal medial e ao giro lingual. Os resultados indicam, portanto, que existem conexões funcionais do NAcc e da amígdala especificamente associadas aos TCD ou ao TDAH e que comportamentos atípicos comuns a ambos os transtornos estão relacionados a alterações na conectividade funcional do NAcc e da amígdala. Concluindo, a abordagem dimensional pode complementar a abordagem categórica na avaliação da neurobiologia dos TCD e do TDAH / Disruptive behavior disorders (DBD), represented by oppositional defiant disorder and conduct disorder, and attention deficit/hyperactivity disorder (ADHD) are intrinsically related disorders. Theories and studies suggest the involvement of regions related to emotional and reward processing, among them the amygdala and the nucleus accumbens (NAcc), in both disorders. Evaluating brain connections of the NAcc and of the amygdala in DBD and in ADHD may contribute to elucidate the neurobiology of the disorders and of related behaviors. The objective of this study was to characterize functional connectivity of the NAcc and of the amygdala in children with ADHD and with DBD, and to evaluated the relationship between functional connectivity of those regions and atypical behaviors characteristic and common to both disorders. In this study, children (mean age= 11.28 years) classified as DBD (n=22), ADHD (n=25), or typical development (TD; n=236) underwent resting-state functional magnetic resonance imaging session. Whole-brain resting-state functional connectivity of 2 regions of interest (NAcc and amygdala) was evaluated. In a categorical approach, connectivity maps were compared between groups. Furthermore, in a dimensional approach, functional connectivity of the NAcc and of the amygdala was correlated to scores in 3 behavior dimensions: inattention/hyperactivity, aggressiveness, and conduct problems, producing 3 correlation maps (connectivity vs. behavior) for each region. For this phase the entire sample was included (n=283). Results from the categorical approach showed some connections specific to DBD and to ADHD. NAcc connections to posterior insula and to precuneus differed DBD from TD and from ADHD. The connection between amygdala and lingual gyrus differed ADHD from TDC and from DBD. ADHD also exhibited atypical amygdala connectivity with precentral gyrus and with inferior parietal lobule, compared to children with TD. There was no altered NAcc functional connectivity in children with ADHD or altered amygdala functional connectivity in children with DBD, compared to children with TD. The dimensional approach showed a different pattern of results. Inattention/hyperactivity and aggression scores were associated with NAcc connectivity to fusiform gyrus and dorsomedial prefrontal cortex. Inattention/hyperactivity was correlated with amygdala connectivity to inferior parietal lobule, middle temporal gyrus, and superior precentral sulcus. Aggression was related with amygdala connectivity to precuneus and superior frontal gyrus. Conduct problems were correlated with NAcc-superior frontal gyrus connectivity, and with amygdala connectivity to posterior cingulate cortex, precuneus, medial prefrontal cortex, and lingual gyrus. Results indicate, therefore, that there are NAcc and amygdala functional connections specifically associated with DBD or with ADHD, and that atypical behaviors common to both disorders are related to changes in functional connectivity of the NAcc and of the amygdala. In conclusion, the dimensional approach may complement the categorical approach in evaluating the neurobiology of DBD and of ADHD

Background: The role of the placenta in fetal programming has been recognized as a highly significant, yet often neglected area of study. We investigated placental size in relation to psychopathology, in particular attention deficit hyperactivity disorder (ADHD) symptoms, in children at 8 years of age, and later as adolescents at 16 years. Methodology/Principal Findings: Prospective data were obtained from The Northern Finland Birth Cohort (NFBC) 1986. Placental weight, surface area and birth weight were measured according to standard procedures, within 30 minutes after birth. ADHD symptoms, probable psychiatric disturbance, antisocial disorder and neurotic disorder were assessed at 8 years (n = 8101), and ADHD symptoms were assessed again at 16 years (n = 6607), by teachers and parents respectively. We used logistic regression analyses to investigate the association between placental size and mental health outcomes, and controlled for gestational age, birth weight, socio-demographic factors and medical factors, during gestation. There were significant positive associations between placental size (weight, surface area and placental-to-birth-weight ratio) and mental health problems in boys at 8 and 16 years of age. Increased placental weight was linked with overall probable psychiatric disturbance (at 8y, OR = 1.14 [95% CI = 1.04-1.25]), antisocial behavior (at 8 y, OR = 1.14 [95% CI = 1.03-1.27]) and ADHD symptoms (inattention-hyperactivity at 16y, OR = 1.19 [95% CI = 1.02-1.38]). No significant associations were detected among girls. Conclusions/Significance: Compensatory placental growth may occur in response to prenatal insults. Such overgrowth may affect fetal development, including brain development, and ultimately contribute to psychopathology.

The Amphetamine Years is a history of psychostimulant drugs and their clinical applications in post-World War II American medicine. Comprising such well-known substances as the amphetamines (Benzedrine, Dexedrine), methylphenidate (Ritalin), and phenmetrazine (Preludin), this class of pharmaceuticals has been among the most widely consumed in the past half-century. Their therapeutic uses for a variety of indications such as depression, obesity, and attention-deficit/hyperactivity disorder (ADHD) in children, not to mention their relevance for a number of different medical specialties, reveals that psychostimulants have occupied an important, if underappreciated role in the practice of modern medicine. In this dissertation, I illuminate the various ways in which physicians, particularly psychiatrists, put these drugs to work in clinical practice. In short, I contend that physicians exploited the wide range of physiological and psychological effects of psychostimulants and made a place for them in different therapeutic settings, even ones characterized by competing views and theories about the workings of the human body and mind. My dissertation is distinguished by two prominent themes. First, I emphasize the clinician perspective as a vehicle for understanding the history of the psychostimulants, as well as related developments in psychiatry, pharmacotherapy, and the political economy of drugs, in the second half of the twentieth century. Scholars such Nicolas Rasmussen, David Courtwright, and Ilina Singh have elucidated the history of psychostimulants by emphasizing how pharmaceutical companies positioned their products in the medical marketplace. My dissertation takes a different, yet complimentary approach by studying clinicians, themselves, to further historical comprehension of the place of these pharmaceuticals within postwar medicine, society, and culture. Second, I advance the concept of "therapeutic versatility" to explain their historical trajectories. The complex set of psychological and physical effects these drugs produced made them ideal for a diverse range of therapeutic applications, which explains why they were embraced by many different medical specialties, why they were marketed by manufacturers for a variety of indications, and why they have enjoyed an enduring therapeutic lifespan, in spite of increasing efforts since the mid-1960s to regulate their availability and control their consumption. In addition to these two overarching themes, I advance five specific arguments in my dissertation. First, I contend that pharmaceutical markets were simultaneously created by the drug industry and clinicians. Pharmaceutical firms' efforts to develop markets for their products have been well documented by historians, but in my dissertation, I underscore the role also played by clinicians in discerning drugs' applications. Second, I argue that twentieth-century psychiatry's conception of illness and therapeutics may not be served best by strictly dividing its history along lines of institutional and outpatient treatment. Third, I demonstrate how the use of psychostimulants by analytically oriented psychiatrists during the 1950s complicates historical notions of paradigm shift from a psychodynamic to biological orientation. Psychotherapy and psychopharmacology were not competing paradigms; in practice, doctors often employed both. Fourth, I assert that an appreciation of psychiatrists' empirical and eclectic approaches to the use of drugs is necessary to comprehend the rise of psychiatric pharmacotherapy in the postwar era. Finally, I contend that in order to understand the relationship between medical applications of psychostimulants and their extramedical consumption, it is necessary to conceive of a plurality of distinct "amphetamine cultures," each characterized by a unique set of relationships between physician-prescribers, patient-consumers, pharmaceutical firms, and political authorities.

Thèse numérisée par la Division de la gestion de documents et des archives de l'Université de Montréal

The purpose of this investigation was two-fold. First, to examine the level of diagnostic accuracy of psychologists when their decisions were subjected to statistical procedures that analyzed group differences and group membership predictions. Second, to examine the sensitivity of the Wisconsin Card Sorting Test (WCST; Heaton, Chelune, Talley, Kay, & Curtiss, 1993) in differentially identifying children who experience ADHD and RD-LD symptoms. The diagnostic battery used to identify ADHD, RD-LD, and Normal subjects included intellectual, academic achievement, attention, and hyperactivity measures recognized as sensitive to these disorders. Performance on the WCST was then examined to determine its usefulness in discriminating between the aforementioned groups.Scores for the diagnostic variables for 115 subjects (mean age = 9.8 years; males = 80; females = 35) were analyzed using oneway ANOVAs to determine differences between groups. A subsequent cluster analysis was conducted using Ward's method to determine group membership of the subjects and resulted in a sample of 87. This cluster analysis resulted in a four cluster solution with the groups being identified as ADHD, RD-LD, Normal, and "Close Calls."Two linear discriminant analyses were performed with the first using the diagnostic groups diagnosed by the previous psychologists as groups and diagnostic variables as predictors. The second used the diagnostic groups diagnosed by evaluating psychologists and the WCST variables used as predictors to examine their ability to discriminate between groups and predict membership.The first linear discriminant analysis yielded two significant functions of three indicating confidence in the diagnoses provided by the evaluating psychologists. The second linear discriminant analysis yielded no significant findings when using the WCST variables as predictors. As a result, it appears the WCST provides little useful information in the differentiation between ADHD, RD-LD, and normals. / Department of Educational Psychology

This research explores the manifestation of dual exceptionality, regarding self-image and the experiences students have had with classmates and teachers. The sample was comprised of four students ages 8 to 15 that exhibited ADHD with giftedness and ASD with giftedness. In-depth interviews were conducted with the students. Results showed that students who had a notion of their discrepancies were motivated towards learning, but became bored when tasks were not challenging. They also had good relationships with their teachers and peers. However, meaningful social interactions had a negative connotation for the gifted/ASD group. Implications for research and practice are discussed further. / El presente estudio explora la construcción de autoimagen y el tipo de experiencias ocurridas con compañeros y profesores en la condición de doble excepcionalidad. Se analizan cuatro casos de estudiantes de 8 a 15 años que presentaban trastorno de déficit de la atención (TDAH) con alta capacidad y trastorno del espectro autista (TEA). Los resultados indican que los estudiantes presentaban una noción de la discrepancia de su condición a pesar de desconocerla; estaban motivados al aprendizaje, pero se aburrían con tareas poco desafiantes o repetitivas; presentaban buena relación con profesores y compañeros, sin embargo, para el grupo de estudiantes con alta capacidad y TEA existía una connotación negativa. Se discuten implicancias para la investigación y práctica educativa. / Esta pesquisa explora a manifestação da dupla excepcionalidade referente à construção da autoimagem e o tipo de experiências com colegas e professores. Os casos de quatro (4) estudantes de 8 a 15 anos que apresentavam transtorno do déficit de atenção (TDAH) com alta capacidade e transtornos do espectro autista (TEA) com alta capacidade, foram anali- sados. Os resultados indicam que os estudantes tinham uma noção da discrepância de sua condição, apesar de ignorá-la. Eles estavam motivados a aprender, mas ficavam entediados com tarefas pouco desafiantes ou repetitivas. Além disso, apresentavam boas relações com colegas e professores, no entanto, para o grupo de alunos com TEA e alta capacidade, esta relação tinha uma conotação negativa. As implicações para a pesquisa e a prática educativa, são discutidas.

Partimos da evidência no discurso contemporâneo do excesso de diagnóstico de hiperatividade. Nossa pesquisa realizada em CAPSi (Centro de Atenção Psicossocial Infanto-Juvenil) constatou a utilização do termo Imperativo ou criança imperativa para nomear essas crianças. O funcionamento hiperativo pode se beneficiar da leitura da psicanálise, que destaca os diversos níveis em que o imperativo atinge o sujeito. Isto foi possível a partir de nossa adesão a sublinha de pesquisa Limites, fronteiras e endereçamentos entre mãe e criança de Nanette Zmeri Frej. Conforme o movimento da Aufhebung freudiana apresentado por Frej (2003), as primeiras fronteiras vão estruturar o eu como algo distinto do objeto e as funções da Atenção e da Motricidade (eixos no diagnóstico do transtorno da hiperatividade). Outro limite ao movimento pode ser situado no Complexo de Édipo que interdita o incesto e regula as relações humanas. Este limite também terá influência na Atenção, na Motricidade e, sobretudo na conduta, que pode ser transgressiva. (Forma outro eixo diagnóstico). Essas considerações contribuíram para nos aproximar do modo como os profissionais do CAPSi entendem uma criança hiperativa e seu tratamento. A aproximação se deu também através de entrevistas semi-estruturadas às profissionais que trabalham com as crianças que têm o diagnóstico pesquisado sobre a concepção que têm dessas crianças e o tratamento realizados com elas. Constatamos que a hiperatividade das crianças está relacionada aos problemas das primeiras fronteiras que distinguem o eu do mundo externo. Eu-outro como se vê em sua ausência de endereçamento, já que não param e que muito da hiperatividade e dos transtornos de conduta representam conflitos da criança e do adolescente com a Lei Edípica, exemplificados nas falas reportadas pelas profissionais: Me ensine a ficar quieto! A obedecer! Isso nos permite identificar que, ao lado das intervenções disciplinares, expressas no dar limites às crianças, as profissionais tentam dar conta dos limites constitutivos em suas intervenções, fazem hipóteses nas crianças de sujeito e consideram também os endereçamentos nas relações delas a seus Outros. Ao final, constatamos a importância do próprio CAPSi não ceder aos imperativos de produtividade e de esquecer dos limites de suas intervenções que precisa considerar a interdisciplinaridade e a atuação em Rede a fim de que ele próprio não fique hiperativo. / It is evident nowadays the over-diagnosis of hyperactivity. Our survey in CAPSi (Center of Psychosocial Care of Children and Adolescents ) found the using of "imperative " or "imperative child " to name these children . The hyperactive functioning can be elucidated by psychoanalysis reading which highlights the various levels at which the imperative reaches the subject. This can be done by the adherence to the sub - line search: Limits, boundaries and addressments between mother and child of Nanette Zmeri Frej. As the Freudian Aufhebung movement presented by Frej (2003), the first boundary will structure the self as distinct from the object and the functions of Attention and Motricity (axes in the diagnosis of hyperactivity disorder). Another limit to this movement can be situated on the Oedipus Complex that interdicts the incest and regulates human relationships. This limit will also have influence on Attenction, Mobility and above all on the conduct, which could be transgressive. (Another diagnosis axe). These considerations have approached us the way professionals understand the CAPSi, a hyperactive child and its treatment. This approach was also possible through semi-structured interviews to professionals who work with children diagnosed asking these professionals about their concept about the problem and how they treat them.We found that hyperactivity of children deal with the problems of the first boundaries that distinguish the self from the external world and self-other as seen in the absence of addressment, since " they dont stop " and many of the hyperactivity and conduct disorders represent conflicts of children and adolescents with Oedipal Law, exemplified in the statements reported by professionals: " Teach me to be quiet ! " "to be obedient! " We identify in one hand the disciplinary interventions, expressed in "setting limits" to the children and on the other hand the CAPSis staff attempting to account for the constitutive limits of children, making a subject hypothesis to them and also considering their addressments to their Other. Finally, we note how important is the CAPSi not be guided through imperatives of productivity up to the point of forgetting the limits of their interventions and the need of interdisciplinary and territory networking performance otherwise the CAPSi could become hyperactive itself.

Hyperactivity and attention deficit disorder belong to very complicated disorders which should be considered in a global view. At present no general or miracle medicine can be used. However, specific learning disabilities and ADHD are focused on very intensively at basic schools in the Czech Republic. Children´s aggressiveness, hyperactivity and difficulties in raising are discussed very often. No programme or method can substitute a nice family life, loving parental care and good relations in the family. However, many cases of destroying a contended family life caused by child´s disorders or disharmony are reported. Even the best family is not expected to be able to bring up a hyperactive child by itself. The dissertation is focused on children who suffer from functional disorder called ADHD syndrom. First part of the work is divided into chapters which detail ADHD terminology, its historical development, symptoms, probable causes, diagnostics and ways of dealing with it in general. Further chapters analyse specific learning disabilities which are closely related to ADHD. The goal of the work consists in emphasising importance of self-help societies and civic associations at local and national dimensions. Next part concerns with the study on current situation of the care and service provided for ADHD children and their families in the region of Česká Lípa.Children´s parents were asked to fill in the questionnaire in order to find out their opinions and needs, and if they are satisfied with services provided for their children. They were also informed about the self-help societies and civic associations and ways of establishing local ones. The work should draw attention to the disorders mentioned above and most of all emphasise the importance of civil sector which plays a significant role in dealing with these problems. The author would also like to refer to the necessity of improving lives of these childrens and their close relatives.

Introdução O Transtorno de Déficit de Atenção/hiperatividade (TDAH) tem sido muito estudado, mas informações econômicas referentes ao seu tratamento com o metilfenidato de liberação imediata (MFD-LI) ainda necessitam ser exploradas. Grande parte da população mundial, principalmente aqueles que vivem em países em desenvolvimento, utiliza essa formulação como principal escolha para o tratamento do TDAH. Esses países, por sua condição financeira, necessitam informações de análises econômicas para administrar de forma eficiente os recursos públicos destinados aos setores da saúde. Objetivos Avaliar a eficácia do MFD-LI através de estudos com tempo superior a 12 semanas, e realizar uma análise econômica para o tratamento do TDAH com MFD-LI para crianças e adolescentes brasileiros. Método O estudo foi planejado em cinco etapas: 1) estimativa de custo do não tratamento do TDAH para o Brasil, e estimativa de economia com tratamento com MFD-LI; 2) revisão sistemática da literatura nas principais bases de dados internacionais onde se buscaram estudos abertos com tratamento do TDAH com MFD-LI por tempo igual ou superior a 12 semanas; também foram feitas metanálises e uma metaregressão 3) estudo naturalístico para obterem-se dados de uma amostra brasileira referentes a probabilidades de uso e sucesso com tratamento com MFD-LI por 12 semanas, e estimar os utilities desses indivíduos; 4) painel Delphi com especialistas em TDAH no Brasil; 5) estudo de custo-efetividade para o tratamento do TDAH com MFD-LI no Brasil, utilizando um Modelo de Markov. A perspectiva adotada será a do sistema público de saúde brasileiro como pagador. Resultados Os resultados principais encontrados para cada uma das etapas foram: 1) a estimativa de custos anuais com o TDAH não tratado no Brasil foi de R$ 1.594 bilhões/ano, e da quantia que poderia ser economizada se tratado, R$ 1 bilhão/ano. 2) na revisão sistemática da literatura, de 4.498 resumos, sete foram incluídos para compor a metanálise. O tempo de tratamento variou entre 13 e 104 semanas. O efeito agregado para desatenção e hiperatividade medida pelos pais, respectivamente, foi 0.96 (95%CI 0.60 - 1.32) e 1.12 (95%CI 0.85 - 1.39), e pelos professores 0.98 (95%CI 0.09 - 1.86) e 1.25 (95% CI 0.7 - 1.81). A metaregressão não mostrou associação entre as variáveis idade, qualidade do artigo e tempo de tratamento com heterogeneidade. 3) no estudo naturalístico, de 171 pacientes avaliados, 73 forneceram informações para o baseline, e 56 para a 12a semana de tratamento com MFD-LI. Os utilities para um paciente com TDAH não tratado (baseline) foram 0.69 (crianças) e 0.66 (adolescentes), e estimaram-se ganhos entre 0.09 a 0.10 utilities/mês, se tratados adequadamente. 4) no painel Delphi, de 26 especialistas, 14 responderam o questionário online, e foi estimado que a probabilidade dos pacientes não tratados se manterem sintomáticos na 12a semana seria de 91%, e 9% a probabilidade de melhora espontânea; 5) no estudo de custo-efetividade, para o caso base, estimou-se que o Incremental Cost Effectiveness Ratio (ICER) seja I$9,103/QALY (Quality Adjusted Life Years) para crianças e I$11,883/QALY para adolescentes em um horizonte temporal de 06 anos. Para os cenários mais desfavoráveis, os ICERS mais elevados foram I$95,164/QALY para 50% de sucesso com o tratamento, e I$15,000/QALY para 70% de adesão em um horizonte temporal de 06 anos. Conclusões O MFD-LI é um tratamento eficaz para crianças e adolescentes, por um período superior a 12 semanas. Entretanto, o Brasil pode estar aumentando os custos referentes à saúde por não estar fornecendo um tratamento eficaz e economicamente acessível para o TDAH. O tratamento mostrou ser uma opção custo-efetiva para crianças e adolescentes brasileiros, mesmo em cenários desfavoráveis para o tratamento. / Introduction Attention-Deficit/Hyperactivity Disorder (ADHD) is a well-known psychiatric disorder, but some economical aspects of the treatment with Methylphenidate Immediate-release (MPH -IR) still need to be explored. A large number of people around the world, most living in Low-Middle Income Countries (LMIC), use this formulation as the first choice for ADHD treatment. These countries, due to their financial condition, need information from health economic analyzes to efficiently manage the public resources allocated to the health sector. Objective To study the efficacy of MPH-IR reviewing studies conducted for more than 12 weeks long, and to perform an economic analysis for the treatment of ADHD with MPH-IR for Brazilian children. Method The study was planned in a five stages process: 1) to estimate the cost of untreated ADHD for Brazil, and to estimate the savings if MPH-IR were adequately provided; 2) systematic review of the literature to identify papers published where young patients with ADHD were treated with MPH-IR for more than 12 weeks, and to perform a meta-analysis and a meta-regression; 3) to conduct a naturalistic study with a Brazilian sample to collect the probabilities of use and success with the MPH-IR treatment for 12 weeks, and to estimate the utilities; 4) to perform a Delphi panel with ADHD Brazilian experts; 5) to conduct a cost-effectiveness analysis for the treatment of ADHD with MPH-IR in Brazil, using a Markov model. The perspective is the one of the Brazilian public health system as the payer. Results The main findings for each step were: 1) the estimated annual expenditures with untreated ADHD in Brazil were R$1.594billon/year, and the estimated amount that could be saved was R$1billion/year; 2) in the systematic review, from 4,498 abstracts, 7 studies were selected. The length of treatment ranged from 13 to 104 weeks. The aggregate effects for inattention and hyperactivity, according to parents evaluations were respectively 0.96 (95%CI 0.60 - 1.32) and 1.12 (95%CI 0.85 - 1.39), and for teachers 0.98 (95%CI 0.09 - 1.86) e 1.25 (95% CI 0.7 - 1.81). There was no evidence of association between heterogeneity and the variables, age, paper quality and length of treatment; 3) in the naturalistic study, from 171 patients assessed, 73 provided information in the baseline, and 56 in the 12th week of MPH-IR treatment. Utilities for an untreated ADHD patient (baseline) were 0.69 (children) and 0.66 (adolescents), and it was estimated a gain ranging from 0.09 to 0.10 utilities/month if subjects were properly treated; 4) in the Delphi Panel, 26 experts were addressed and 14 filled in the online questionnaire. It was estimated the probability of untreated patients to remain symptomatic on the 12th week to be 91%, and the probability of spontaneous improvement, 9%; 5) in the cost-effectiveness analysis, for the base case, it was estimated an Incremental Cost Effectiveness Ratio (ICER) of I$9,103/QALY (Quality Adjusted Life Years) for children and I$11,883/QALY for adolescents, in a time horizon of 6 years. The worst case scenarios were also tested, and the highest ICER were I$95,164/QALY when patient reached 50 % of success with the treatment, and I$15,000/QALY if only 70% of use was observed in a time horizon of 6 years. Conclusions MPH-IR is an efficacious treatment for ADHD children and adolescents for periods longer than 12 weeks. However, Brazil may be probably wasting money due to not provide an efficient and affordable treatment for ADHD such as the MPH-IR. The treatment proved to be cost-effective for children and adolescents living in Brazil, even when the worst case scenarios were tested.

Made available in DSpace on 2014-07-29T15:29:07Z (GMT). No. of bitstreams: 1 Dissertacao Paulo Verlaine.pdf: 2471983 bytes, checksum: 2b5b94d2bdbc742306bf943ccad71d80 (MD5) Previous issue date: 2009-02-04 / Few studies have been carried out worldwide about ADHD among indigenous children and no study has been conducted in Brazil so far. This study aims to evaluate the estimated prevalence of ADHD among the indigenous populations of Karajá children and adolescents aged 7 to 14 years old. Three of the largest settlements pertaining to this ethnic group were investigated and a sample of 144 subjects of a total population of 350 individuals was collected. The sample was randomly collected and stratified according to the age bands and gender (male and female) proportionally to the size of each participating settlement. Both the CBCL/6-18 (Child Behavior Checklist for ages 6 18) and the TRF (Teacher s Report Form 6-18) were used as instruments of epidemiological tracking of behavioral and emotional problems. Of these instruments, the data used were those compatible with the DSM-IV and ADHD diagnoses as well as Affective Disorder, Anxiety Disorders, Oppositional Defiant Disorders and Conduct Disorders comorbidities. The results indicate a prevalence of 10.4% (95% CI 6.6 14.2) when the respondents are either the parents or the guardians and 2.8% (95% CI 0.7 4.8) when the respondents are the teachers. Of the 144 interviewed participants, 30 had ADHD and comorbidities were 86.7% (95% CI 74.5 98.8) for conduct disorders, 86.7% (95% CI 74.5 98.8) for oppositional defiant disorders, 83.3% Abstract xxviii (95% CI 70.0 96.7) for anxiety disorders and 60% (95% CI 42.5 77.5) for affective disorders. ADHD is then concluded to exist in a population so culturally diverse from that of the east white and to have a high prevalence rate and the comorbidities routinely found in all populations of children from a number of diverse cultures around the globe. / Poucos estudos foram realizados no mundo sobre o TDAH em crianças indígenas, e nenhum no Brasil, até o momento. O objetivo deste estudo é avaliar a prevalência estimada do TDAH na população de crianças e adolescentes índias Karajá, na faixa etária dos 07 aos 14 anos de idade. Três das maiores aldeias dessa etnia foram investigadas, tendo-se colhido de uma população total de 350 indivíduos na faixa de estudo uma amostra de 144 sujeitos. A amostra foi colhida de forma aleatória, com estratificação conforme as faixas etárias e o sexo (feminino e masculino), proporcionalmente ao tamanho de cada aldeia participante. Foram empregados os instrumentos de rastreamento epidemiológico de problemas comportamentais e emocionais CBCL/6-18 (Inventário de Comportamentos para Crianças e Adolescentes de 6 a 18 anos) e TRF (Inventário de Comportamentos Referidos pelo Professor para Alunos de 6 a 18 anos). Desses instrumentos utilizaram-se os dados compatíveis com os diagnósticos pelo DSM-IV do TDAH, bem como para os Transtornos Afetivos, Transtornos de Ansiedade, Transtorno Opositor Desafiante e o Transtorno de Conduta. Os resultados obtidos indicam uma prevalência de 10,4% (IC 95% 6,6 14,2) quando os respondentes são os pais ou responsáveis e de 2,8% (IC 95% 0,7 4,8) quando os respondentes são os professores. Dos 144 entrevistados, 30 eram portadores do TDAH, e as Resumo xxvi comorbidades foram de 86,7% (IC 95% 74,5 98,8) com transtorno de conduta, 86,7% (IC 95% 74,5 98,8) com transtorno opositor desafiante, 83,3% (IC 95% 70,0 96,7) com transtornos de ansiedade e 60% (IC 95% 42,5 77,5) com transtornos afetivos. Conclui-se que o TDAH existe numa população culturalmente tão diversa da branca ocidental, bem como com uma alta taxa de prevalência, com as comorbidades habitualmente encontradas em todas as outras populações de crianças das mais variadas culturas ao redor do mundo.