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Doporučené postupy psychiatrické péče
Psychiatrické společnosti ČLS JEP

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Autoři: Radek Ptáček, Michal Goetz

Garant: Michal Goetz

Oponent: Petra Uhlíková

Hyperkinetické poruchy (ADHD) u dětí

 

Hyperkinetické poruchy (ADHD) u dětí

 

Hyperkinetické poruchy (ADHD) u dětí

 

Hyperkinetické poruchy (ADHD) u dětí

Vysvětlivky:
ovál - nadpis 
kosočtverec - výběr z více variant
přerušovaná čára - diagram pokračuje na další straně 

 

Závěrečný komentář

Vodítka léčby HKP vycházejí z mezinárodních vodítek a jsou rozdělena do dvou oddělených schémat. Schéma 1 se týká Poruchy aktivity a pozornosti, a zahrnuje dva odlišné postupy: první u nekomplikované formy poruchy, druhý u poruchy s komorbiditami a specifickými problémy. Schéma 2 pojednává léčbu Hyperkinetické poruchy chování a představuje jediný postup.
Ke schématu 1: Při formulaci léčebných postupů u Poruchy aktivity a pozornosti je možné vyjít z doporučených postupů léčby pro děti s AD/HD bez komorbidity podle DSM-5. Oba klasifikační systémy považují pro diagnózu za určující shodné symptomy, i když podle DSM-5 tyto symptomy mohou - ale také nemusejí - být přítomny vždy současně. Je nutná pouze modifikace vzhledem k rozdílnému sortimentu registrovaných preparátů v příslušných zemích. V naší republice je možné volit formu metylfenidátu s okamžitým uvolňováním, nebo s prodlouženým uvolňováním a nově je registrován též lisdexamfetamin jež má prodloužený účinek. Individuální volba musí zohlednit compliance pacienta, aby bylo zajištěno spolehlivé zajištění lékem během dne. Jestliže rodiče léčbu stimulancii odmítají nebo jsou kontraindikována nebo jsou přítomny některé komorbidní poruchy (tiky, výrazná anxieta, riziko vzniku závislostí), měl by být u F90.0 použit atomoxetin nebo guanfacin.
Ke schématu 2: Pro léčbu hyperkinetické poruchy chování (podle MKN-10) lze podle názoru expertů pracovní skupiny Global ADHD Working Group (Remschmidt, 2005) aplikovat postup, který je ve standardech pro léčbu ADHD uváděn pro případy komorbidního výskytu ADHD s poruchami chování. Pokud však u hyperkinetické poruchy chování (podle MKN-10) nejsou poruchy chování příliš závažné (na příklad není přítomna závažná agresivita a disociální jednání) a behaviorální problémy splňují spíše kritéria pro poruchu opozičního vzdoru, lze také aplikovat doporučený postup léčby platný pro poruchu pozornosti s hyperaktivitou ( resp. pro AD/HD bez komorbidity).

V posledních letech byla publikována řada meta analytických studií, které se zabývají účinností nefarmakologických postupů (např.: Arns a kol., 2009; Sonuga-Barke a kol., 2013; Catala-Lopez a kol., 2017). Tyto práce poukazují na metodologické nedostatky klinických studií u non-farmakologických postupů a malý počet studí. Není tak v řadě případů doposud popsaná přesná indikace, standardizované postupy ani dostatečně velikost efektu ve srovnání s jinými metodami.
Nicméně, současná meta-analýza uzavírá, že behaviorální terapie zejména je-li poskytována rodiči s aktivním zapojením dítěte a učitele je jediným nefarmakologickým postupem, který prokázal statisticky signifikantní efekt na zmírnění symptomů poruchy (Catala-Lopez a kol., 2017)
Kognitivní trénink, neurofeedback, dietní opatření, užívání nenasycených mastných kyselin, aminokyselin, minerálů, bylinná terapie a fyzická aktivita nemohou být označeny jako prokazatelně účinná a specifická léčba poruchy pozornosti s hyperaktivitou (Sonuga-Barke et al. 2013,Lofthouse et al. 2012, Catala-Lopez a kol., 2017 ).

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Datum zveřejnění: 10.6.2018

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