Transtorno de déficit de atenção/hiperatividade com predomínio de desatenção : genes de susceptibilidade e influência de fatores ambientais

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Socio-demographic and clinical characteristics of pregnant and puerperal crack-cocaine using women: preliminary data

Background The literature provides several studies on the effects of cocaine when exposed to the fetus. However, the majority of these data comes from animal models. Objective The objective of this study is to present socio-demographic and clinical data in crack-cocaine using pregnant women and their babies, as compared to non-users. Methods Cross-sectional study, comprised by 56 dyads of crack-cocaine using mothers-babies and 89 control dyads. In addition to the socio-demographic data and the babies’ information, data collection was based on ABIPEMI for socioeconomic level, WAIS for IQ, MINI for psychopathology and ASSIST for drug use. Results Most crack users, in comparison to non-users, did not have a partner (10.52% vs 4.4%, P = 0.001) and presented lower IQ (78.15, +/-8.07 vs 84.27 +/- 9.87; P = 0.002). The prevalence of antisocial personality disorder and suicide risk in users was higher than in non-users (24.44% vs none, P < 0.001; 28.26% vs 10.46% P = 0.01). Most of the users did not participate in prenatal care (75%). The babies that the crack-cocaine using mothers gave birth to weighed significantly less than the controls (2.858 g vs 3.240 g, P = 0.002). Discussion Users had a higher degree of psychopathology and lower attendance in prenatal care. There was an overlap of adverse factors, both for exposed mothers and babies. The sum of these vulnerabilities could result in significant harm to the developing infant

Níveis de IL-6 e IL-10 no sangue de cordão umbilical de recém-nascidos com história de exposição intrauterina ao crack/cocaína : um estudo comparativo

Introduction: Prenatal cocaine exposure (PCE) is associated with neurobehavioral problems during childhood and adolescence. Early activation of the inflammatory response may contribute to such changes. Our aim was to compare inflammatory markers (IL-6 and IL-10) both in umbilical cord blood and in maternal peripheral blood at delivery between newborns with history of crack/cocaine exposure in utero and non-exposed newborns. Methods: In this cross-sectional study, 57 newborns with a history of crack/cocaine exposure in utero (EN) and 99 non-exposed newborns (NEN) were compared for IL-6 and IL-10 levels. Sociodemographic and perinatal data, maternal psychopathology, consumption of nicotine and other substances were systematically collected in cases and controls. Results: After adjusting for potential confounders, mean IL-6 was significantly higher in EN than in NEN (10,208.54, 95% confidence interval [95%CI] 1,328.54-19,088.55 vs. 2,323.03, 95%CI 1,484.64-3,161.21; p = 0.007; generalized linear model [GLM]). Mean IL-10 was also significantly higher in EN than in NEN (432.22, 95%CI 51.44-812.88 vs. 75.52, 95%CI 5.64- 145.39, p = 0.014; GLM). Adjusted postpartum measures of IL-6 were significantly higher in mothers with a history of crack/cocaine use (25,160.05, 95%CI 10,958.15-39,361.99 vs. 8,902.14, 95%CI 5,774.97-12,029.32; p = 0.007; GLM), with no significant differences for IL-10. There was no correlation between maternal and neonatal cytokine levels (Spearman test, p ≥ 0.28 for all measures). Conclusions: IL-6 and IL-10 might be early biomarkers of PCE in newborns. These findings could help to elucidate neurobiological pathways underlying neurodevelopmental changes and broaden the range of possibilities for early intervention.Introdução: A exposição pré-natal à cocaína está associada a problemas neurocomportamentais durante a infância e adolescência. A ativação precoce da resposta inflamatória pode contribuir para tais alterações. Nosso objetivo foi comparar marcadores inflamatórios (IL-6 e IL-10) no sangue do cordão umbilical e no sangue periférico materno na hora do parto, entre recém-nascidos expostos ao crack intraútero e recém-nascidos não expostos. Métodos: Neste estudo transversal, 57 recém-nascidos expostos ao crack intraútero (RNE) e 99 recém-nascidos não expostos (RNNE) foram comparados quanto aos níveis de IL-6 e IL-10. Dados sociodemográficos e perinatais, psicopatologia materna, consumo de nicotina e outras substâncias foram sistematicamente coletados em casos e controles. Resultados: Após o ajuste para potenciais confundidores, a média de IL-6 foi significativamente maior nos RNE em comparação aos RNNE [10.208,54, intervalo de confiança (IC95%) 1.328,54- 19.088,55 versus 2.323,03, IC95% 1.484,64-3.161,21; p = 0,007; modelo linear generalizado (MLG)]. A média ajustada de IL-10 foi significativamente maior nos RNE do que nos RNNE (432,2189, IC95% 51,44-812,88 versus 75,52, IC95% 5,64- 145,39, p = 0,014; MLG). Medidas pós-parto ajustadas de IL-6 foram significativamente maiores nas mães que usaram de crack/ cocaína (25.160,05, IC95% 10.958,15-39.361,99 versus 8.902,14, IC95% 5.774,97-12.029,32; p = 0,007; MLG), sem diferenças significativas para IL-10. Não houve correlação entre níveis maternos e neonatais de citocinas (teste de Spearman, p ≥ 0,28 para todas as medidas). Conclusões: IL-6 e IL-10 podem ser biomarcadores precoces da exposição pré-natal a cocaína em recém-nascidos. Esses resultados podem ajudar a elucidar as vias neurobiológicas subjacentes a alterações do desenvolvimento e aumentar a gama de possibilidades para intervenção precoce

Estudo sobre características clínicas e biomarcadores em adolescentes internados por uso de crack

A presente tese aborda o tema da dependência de crack na adolescência, assunto de grande relevância clínica devido à gravidade dos pacientes e à dificuldade em realizar tratamentos eficazes. Ambos os estudos apresentados foram feitos a partir de uma amostra de 90 adolescentes, de 12 a 18 anos incompletos, internados por problemas relacionados ao uso de crack em duas enfermarias na cidade de Porto Alegre, Rio Grande do Sul, Brasil. A amostra consecutiva foi coletada de Maio de 2011 a Novembro de 2012. Também foi coletada uma amostra controle de 81 adolescentes sem uso de drogas, provenientes de um bairro de baixa-renda na região metropolitana de Porto Alegre. Como resultados do primeiro estudo, observou-se que os adolescentes internados por uso de crack apresentaram idade média de 15,6 anos (DP=1,4), e a maioria (85,5%) era do sexo masculino. Todos os pacientes haviam utilizado alguma outra substância psicoativa antes de iniciar o uso de crack: 61,4% tabaco (idade média do primeiro uso 11,6 anos), 44,3% álcool (idade média do primeiro uso 12,4 anos), e 54,5% maconha (idade média do primeiro uso 12,15 anos). A idade média de início do crack foi aos 13,4 anos. Apresentaram alta taxa de comorbidades psiquiátricas, com 81,8% dos pacientes com o diagnóstico de Transtorno de Conduta, 52,3% com Transtorno Opositor Desafiante e 44,3% apresentando Transtorno de Déficit de Atenção e Hiperatividade (todas essas com p<0,001 em relação aos controles). Evidenciamos consequências graves do uso de drogas em todas as áreas da vida (como altos escores de comprometimento nas áreas de uso de substâncias, escola, família e psiquiátrica do questionário Teen Addiction Severity Index – T-ASI). O tempo médio decorrido entre o início de uso de drogas e o início de uso de crack foi de 2,53 anos (DP=1,96). Através do modelos de regressão de Cox, encontramos os seguintes preditores de progressão precoce ao uso de crack: idade de início de uso de qualquer substância e idade no momento da internação. Dando continuidade ao tema desta tese, o segundo artigo abordou os níveis de quatro potenciais biomarcadores para o uso de crack na adolescência. São eles: o Fator de crescimento derivado do cérebro (BDNF), as interleucinas 6 e 10 (IL-6 e IL-10), e as substâncias reativas ao ácido tiobarbitúrico (TBARS). Foram medidos, na mesma amostra de pacientes do primeiro estudo, em dois momentos: no dia seguinte à internação e no momento da alta. Também foram medidos em controles. As análises foram controladas para possíveis confundidores. Encontrou-se níveis significativamente mais baixos de BDNF entre os pacientes (16,61; DP=2,06), em relação aos controles (25,12; DP=175) (p<.001). Os níveis de TBARS estavam significativamente elevados entre os pacientes (25,07; DP=21,83), em relação aos controles (16,46; DP=23,25) (p=0,005). Os níveis de IL-6 estavam significativamente elevados entre os pacientes (577,34; DP=156,11) em relação aos controles (151,91; DP=64,7) (p=0,027). Os níveis de IL-10 estavam significativamente elevados entre os pacientes (383,86; DP= 97,24), em relação aos controles(109,89; DP=40,89) (p=0,025). Concluiu-se que adolescentes internados por uso de crack apresentam problemas em diversas áreas da vida, altas taxas de comorbidade e alterações em biomarcadores específicos relacionados com inflamação e estresse oxidativo. Sugere-se que esta população necessita cuidados especiais para evitar comprometimentos maiores.This thesis is about crack-cocaine dependence in adolescence, a subject that is of high clinical interest due to the severity of the clinical presentation of those patient and the challeng of providing effective treatment. Both studies presented were conducted with a ample of 90 adolescents, from 12 to 18 years age, of both sexes, who had been admitted for problems related to crack-cocaine use in two impatient treatment units for adolescents. In the city of Porto Alegre, south of Brazil. This consecutive sample was collected from May 2011 to November 2012. A control sample of drug-naïve adolescents has been recruited in a low income neighborhood. As results of this first study, it was observed that adolescents admitted for crack-cocaine use had a mean 15.6 years of age, and most of them (85.5%) were male. All patients had used at least one other psychoactive substance before initiating crack-cocaine use: 61.4% had used tobacco (mean age of first use=11.6 years), 44.3 had used alcohol (mean age of first use=12.4 years), and 54.5 5 had used cannabis (mean age of first use = 12.15 years). Mean age of crack-cocaine initiation was 13.4 years. Patients had high rates of comorbid conditions, with 81.8% of patients having a lifetime diagnosis of Conduct Disorder, 52.3% with Oppositional Defiant Disorder, and 44.3% with Attention Deficit and Hyperactivity Disorder. All the comorbid conditions found were more prevalent in the patients group than in controls. The T-ASI interview showed severe consequences of crack-cocaine abuse in all life areas. Mean time from first substance use to first use of crack cocaine was 2.5 years. By using Cox regression moles, we found that predictors to early crack-cocaine initiation were: age of first substance use and current age. The second study is about four potential biomarkers of crack-cocaine use in adolescence. They are the Brain Derived Neurotrophic Factor (BDNF), the interleukins 6 and 10 (IL-6 and IL-10), and Thiobarbituric acid reactive substance (TBARS). They were measured in peripherical blood, in the same sample of patients from the first study, at two moments: the day after admittance and in the day of discharge from the unit. They were also measured in controls. They were compared using Generalized Estimating Equations, and analyses where controlled by possible confounders. BDNF levels were lower in patients than in controls. TBARS levels were higher in patients than in controls. IL=6 was higher in patients than in controls. IL-10 was higher in patients than in controls. In conclusion, adolescents that are admitted to inpatient units for crack-cocaine-related problems show high degree of impairment in multiple life areas, high rates of comorbid conditions and alterations in biomarkers related to inflammation and oxidative stress. It is suggested that this population need special care to prevent further impairments

Estudo sobre características clínicas e biomarcadores em adolescentes internados por uso de crack

A presente tese aborda o tema da dependência de crack na adolescência, assunto de grande relevância clínica devido à gravidade dos pacientes e à dificuldade em realizar tratamentos eficazes. Ambos os estudos apresentados foram feitos a partir de uma amostra de 90 adolescentes, de 12 a 18 anos incompletos, internados por problemas relacionados ao uso de crack em duas enfermarias na cidade de Porto Alegre, Rio Grande do Sul, Brasil. A amostra consecutiva foi coletada de Maio de 2011 a Novembro de 2012. Também foi coletada uma amostra controle de 81 adolescentes sem uso de drogas, provenientes de um bairro de baixa-renda na região metropolitana de Porto Alegre. Como resultados do primeiro estudo, observou-se que os adolescentes internados por uso de crack apresentaram idade média de 15,6 anos (DP=1,4), e a maioria (85,5%) era do sexo masculino. Todos os pacientes haviam utilizado alguma outra substância psicoativa antes de iniciar o uso de crack: 61,4% tabaco (idade média do primeiro uso 11,6 anos), 44,3% álcool (idade média do primeiro uso 12,4 anos), e 54,5% maconha (idade média do primeiro uso 12,15 anos). A idade média de início do crack foi aos 13,4 anos. Apresentaram alta taxa de comorbidades psiquiátricas, com 81,8% dos pacientes com o diagnóstico de Transtorno de Conduta, 52,3% com Transtorno Opositor Desafiante e 44,3% apresentando Transtorno de Déficit de Atenção e Hiperatividade (todas essas com p<0,001 em relação aos controles). Evidenciamos consequências graves do uso de drogas em todas as áreas da vida (como altos escores de comprometimento nas áreas de uso de substâncias, escola, família e psiquiátrica do questionário Teen Addiction Severity Index – T-ASI). O tempo médio decorrido entre o início de uso de drogas e o início de uso de crack foi de 2,53 anos (DP=1,96). Através do modelos de regressão de Cox, encontramos os seguintes preditores de progressão precoce ao uso de crack: idade de início de uso de qualquer substância e idade no momento da internação. Dando continuidade ao tema desta tese, o segundo artigo abordou os níveis de quatro potenciais biomarcadores para o uso de crack na adolescência. São eles: o Fator de crescimento derivado do cérebro (BDNF), as interleucinas 6 e 10 (IL-6 e IL-10), e as substâncias reativas ao ácido tiobarbitúrico (TBARS). Foram medidos, na mesma amostra de pacientes do primeiro estudo, em dois momentos: no dia seguinte à internação e no momento da alta. Também foram medidos em controles. As análises foram controladas para possíveis confundidores. Encontrou-se níveis significativamente mais baixos de BDNF entre os pacientes (16,61; DP=2,06), em relação aos controles (25,12; DP=175) (p<.001). Os níveis de TBARS estavam significativamente elevados entre os pacientes (25,07; DP=21,83), em relação aos controles (16,46; DP=23,25) (p=0,005). Os níveis de IL-6 estavam significativamente elevados entre os pacientes (577,34; DP=156,11) em relação aos controles (151,91; DP=64,7) (p=0,027). Os níveis de IL-10 estavam significativamente elevados entre os pacientes (383,86; DP= 97,24), em relação aos controles(109,89; DP=40,89) (p=0,025). Concluiu-se que adolescentes internados por uso de crack apresentam problemas em diversas áreas da vida, altas taxas de comorbidade e alterações em biomarcadores específicos relacionados com inflamação e estresse oxidativo. Sugere-se que esta população necessita cuidados especiais para evitar comprometimentos maiores.This thesis is about crack-cocaine dependence in adolescence, a subject that is of high clinical interest due to the severity of the clinical presentation of those patient and the challeng of providing effective treatment. Both studies presented were conducted with a ample of 90 adolescents, from 12 to 18 years age, of both sexes, who had been admitted for problems related to crack-cocaine use in two impatient treatment units for adolescents. In the city of Porto Alegre, south of Brazil. This consecutive sample was collected from May 2011 to November 2012. A control sample of drug-naïve adolescents has been recruited in a low income neighborhood. As results of this first study, it was observed that adolescents admitted for crack-cocaine use had a mean 15.6 years of age, and most of them (85.5%) were male. All patients had used at least one other psychoactive substance before initiating crack-cocaine use: 61.4% had used tobacco (mean age of first use=11.6 years), 44.3 had used alcohol (mean age of first use=12.4 years), and 54.5 5 had used cannabis (mean age of first use = 12.15 years). Mean age of crack-cocaine initiation was 13.4 years. Patients had high rates of comorbid conditions, with 81.8% of patients having a lifetime diagnosis of Conduct Disorder, 52.3% with Oppositional Defiant Disorder, and 44.3% with Attention Deficit and Hyperactivity Disorder. All the comorbid conditions found were more prevalent in the patients group than in controls. The T-ASI interview showed severe consequences of crack-cocaine abuse in all life areas. Mean time from first substance use to first use of crack cocaine was 2.5 years. By using Cox regression moles, we found that predictors to early crack-cocaine initiation were: age of first substance use and current age. The second study is about four potential biomarkers of crack-cocaine use in adolescence. They are the Brain Derived Neurotrophic Factor (BDNF), the interleukins 6 and 10 (IL-6 and IL-10), and Thiobarbituric acid reactive substance (TBARS). They were measured in peripherical blood, in the same sample of patients from the first study, at two moments: the day after admittance and in the day of discharge from the unit. They were also measured in controls. They were compared using Generalized Estimating Equations, and analyses where controlled by possible confounders. BDNF levels were lower in patients than in controls. TBARS levels were higher in patients than in controls. IL=6 was higher in patients than in controls. IL-10 was higher in patients than in controls. In conclusion, adolescents that are admitted to inpatient units for crack-cocaine-related problems show high degree of impairment in multiple life areas, high rates of comorbid conditions and alterations in biomarkers related to inflammation and oxidative stress. It is suggested that this population need special care to prevent further impairments

Is avoidant disorder part of the social phobia spectrum in a referred sample of Brazilian children and adolescents?

The diagnosis of avoidant disorder was deleted from the Diagnostic and Statistical Manual of Mental disorders - fourth edition (DSM-IV) based on a ‘committee decision’ suggesting that avoidant disorder is part of the social phobia spectrum. The objective of the present study was to examine the nature of this clinical association in a referred sample of Brazilian children and adolescents. We assessed a referred sample of 375 youths using semi-structured diagnostic interview methodology. Demographic (age at admission to the study and sex) and clinical (level of impairment, age at onset of symptoms and pattern of comorbidity) data were assessed in subsamples of children with avoidant disorder (N = 7), social phobia (N = 26), and comorbidity between both disorders (N = 24). Although a significant difference in the male/female ratio was detected among groups (P = 0.03), none of the other clinical variables differed significantly among subjects that presented each condition separately or in combination. Most of the children with avoidant disorder fulfilled criteria for social phobia. Thus, our findings support the validity of the conceptualization of avoidant disorder as part of the social phobia spectrum in a clinical sample

Psychotherapeutic treatment for adolescents with substance abuse

O uso de álcool e demais substâncias psicoativas é um dos problemas de maior prevalência entre adolescentes. Todo adolescente que for avaliado por profissional de saúde deve ser questionado sobre seu uso de álcool e substâncias psicoativas. Em caso positivo, esse uso deve ser investigado clinicamente e, mesmo quando minimamente problemático, o adolescente deve ser encaminhado para tratamento específico. O tratamento deve levar em conta várias particularidades da adolescência para ser efetivo. Há indicação do uso de psicoterapias no atendimento a esses adolescentes. Entre elas, estão a Terapia de Família, a Terapia Cognitivo-Comportamental e a Entrevista Motivacional. Todas essas modalidades de terapia apresentam evidências de eficácia nessa faixa etária e podem ser usadas separadamente ou em conjunto. Essas modalidades de tratamento serão revisadas, sendo explicados seu método de ação e suas principais evidências de eficácia em adolescentesThe use of alcohol and drugs in the adolescence is a common problem. Every teenager that goes through psychological evaluation should be asked about use of alcohol and drugs of abuse. If positive, this use should be clinically investigated and, referred to treatment at the slightest signs of problems. Treatment must take account of age-specific characteristics in order to be effective. There are many kinds of psychotherapies based on evidence for this age group. Among them, are Family Therapy, Cognitive Behavioral Therapy and Motivational Interviewing. Those treatment modalities are addressed, explaining their means of action and their main proofs of efficacy in adolescents

Identification and initial management of intoxication by alcohol and other drugs in the pediatric emergency room

Objective: To review the screening, diagnosis, evaluation, and treatment of intoxication by alcohol and other drugs in children and adolescents in the emergency scenario. Data source: This was a narrative literature review. Data summary: The detection of this problem in the emergency room can be a challenge, especially when its assessment is not standardized. The intentional and episodic use of large amounts of psychoactive substances by adolescents is a usual occurrence, and unintentional intoxication is more common in children younger than 12 years. The clinical picture in adolescents and children differs from that in adults and some particularities are important in the emergency scenario. After management of the acute condition, interventions targeting the adolescent at risk may be effective. Conclusion: The diagnosis and treatment of intoxication by alcohol and other drugs in adolescents and children in the emergency scenario requires a systematic evaluation of the use of these drugs. There are few specific treatments for intoxication, and the management comprehends support measures and management of related clinical complications