CPG on ADHD

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evidence have been solved by consensus of the development group.On some occasions,and for greater transparency, those recommendations that have been adapted from otherguidelines and contextualised in our medium are explicitly established, so that the usercan easily identify in which cases this has occurred. A total of 28 meetings of the developmentgroup have been held during the entire guideline preparation process.• Collaborators in the chapter on ethical and legal aspects.They have participated withtheir experience in reviewing the legislation in force in our medium for children andadolescents with ADHD.• Expert collaborators:They have participated in the preparation process of the scopeand clinical questions to be answered, as well as in the review of the guideline.• External reviewers:Different relevant professionals in the subject have participated inthe review of the draft guideline, as well as scientific societies and representatives ofpatients and family members involved in ADHD in children and adolescents.• To prepare the information for patients, family members and educators (Appendix3), the development group agreed upon an index based on the complete guideline, whichincludes the most relevant aspects that might be of interest to patients, family membersand educators.A summary of the sections of the guideline and of its main recommendationswas prepared based on that index, adapting the information provided, the style andthe language for this section.Although this information forms part of the <strong>CPG</strong> and mustbe presented and explained by the physicians, personalised leaflets to facilitate its disseminationare hoped to be published.• The <strong>CPG</strong> is organised into chapters, where answers are given to the questions that appearat the beginning.Following each question, the documents and quality on whichthe answer is based are described.Afterwards, the results of the scientific evidence arepresented in two blocks:scientific evidence and summary of the scientific evidence. Thescientific evidence section presents the results of the individual studies described in the<strong>CPG</strong>s, SRs and MAs included. The results/conclusions of the <strong>CPG</strong>s, SRs, and MAs areincluded in the scientific evidence summary section. In some questions, to avoid repetitions,only one of these two sections is presented. Finally, the recommendations of thedevelopment group of this <strong>CPG</strong> are presented.Although the first author and the year ofthe individual publications are described in the scientific evidence tables, the results thatappear correspond to the reviewed <strong>CPG</strong>s, SRs or MAs, except when RCTs have beenidentified in the update.The type of study and the quality of the reviewed literature isgiven in the right-hand margin, throughout the text.In the case of the <strong>CPG</strong>s, this is notindicated as they are all quality ones.• The expression “children and adolescents” is constantly repeated throughout this <strong>CPG</strong>,referring to both sexes.• This <strong>CPG</strong> is available on the portal of GuiaSalud (www.guiasalud.es). As well as on theweb page of the AIAQS (www.aiaqs.net) and of the Sant Joan de Deu Hospital (www.hsjdbcn.org).• This <strong>CPG</strong>, published in 2009, will be updated after evaluating any new scientific evidencethat might appear over the next 3 years.Any modification during that time will bereflected in electronic format, which can be consulted on the portal of GuiaSalud andon the web page of the AIAQS.The methodology proposed in the Manual, Update ofClinical Practice Guidelines in the National Health System will be applied to carry outthis update. Methodology Manual 47 of the Ministry of Health and Consumer Affairs.42 CLINICAL PRACTICE GUIDELINE ON ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) IN CHILDREN AND ADOLESCENTS
4. ADHDQuestions to be answered:4.1. How is ADHD defined? What clinical manifestations does the disorder have?4.2. Etiopathogeny of ADHD. What are the main risk factors?4.3. In ADHD: Are there neuropsychological dysfunctions?4.4. What is the natural course of ADHD?4.5. In ADHD: What is the long-term prognosis? What factors have an influence on a good orbad prognosis?To what extent does early diagnosis and intervention improve the prognosisof ADHD?4.6. In ADHD: What are the most frequent comorbid disorders?4.1. How is ADHD defined? What clinical manifestationsdoes the disorder have?Attention deficit hyperactivity disorder (ADHD) is a neurobiological disorder that starts duringchildhood and affects between 3 and 7% of school-aged children.It is characterised by a level ofimpulsivity, activity and attention that are not adequate for the development age.Many childrenand adolescents with ADHD find it difficult to regulate their behaviour and adjust to the rulesexpected for their age and, consequently, they find it difficult to adapt in their family and schoolenvironment, and in their relationships with their peers.They often perform below their capabilitiesand may present emotional and behavioural disorders (APA, 2001) 10 .What are the nuclear symptoms and how are they clinicallymanifested?The data or behaviours that are taken into consideration to evaluate ADHD are dimensional. Theyare distributed continuously going from normality to pathology.The nuclear symptoms are: inattention,hyperactivity and impulsivity, to which comorbidity side effects are often added.According to the DSM-IV-TR (APA, 2001) 10 , the clinical manifestations of the nuclearsymptoms refer to:HyperactivityThis is manifested by excess movement, motor and/or cognitive activity, in situations in which itis inappropriate to do so. These children show a high motor activity in different areas. They havedifficulty keeping quiet when situations require this, both in structured contexts (the classroom ortable at mealtime), and in non-structured contexts (playtime).The developmental moment has a significant influence on the manifestation of the hyperactivity.Thus,the pervasive hyperkinesis of pre-school children is less dependent on the environ-CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 43
Page 3 and 4: Clinical Practice Guidelineon Atten
Page 5: This CPG has been
Page 8 and 9: AppendicesAppendix 1 Levels of evid
Page 10 and 11: We trust that this work will undoub
Page 12 and 13: Jesús Eirís Puñal, neuropaediatr
Page 15 and 16: Questions to be answeredADHD1. How
Page 17 and 18: 39. In which ADHD subtypes is pharm
Page 19 and 20: Recommendations of the CPG<
Page 21 and 22: 6. Assessment instruments6.1. Which
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Page 25 and 26: 7.3.7. In ADHD: How long should the
Page 27 and 28: 7.3.13. What scientific evidence ex
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Page 31 and 32: 9.4. How involved must the minor be
Page 33 and 34: 1. IntroductionBackgroundThe “Evi
Page 35 and 36: Table 1. ADHD prevalence studies in
Page 37: Health RepercussionsThe repercussio
Page 40 and 41: Secondary objectivesa) To generate
Page 42 and 43: • Formulation of clinical questio
Page 46 and 47: ment.At school age, the hyperactive
Page 48 and 49: Volumetric brain studies have shown
Page 50 and 51: 4.4. What is the natural course of
Page 52 and 53: Parents’ psychopathologyIn the st
Page 55 and 56: 5. DiagnosisQuestions to be answere
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Page 59 and 60: Family backgroundSummary of scienti
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Page 66 and 67: 6.1. Which screening instruments an
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Page 70 and 71: Title Authors Year Description Age
Page 72 and 73: RecommendationsC 6.1.1. 6.1.2. 6.2.
Page 74 and 75: 6.5. In ADHD in children and adoles
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Page 79 and 80: Variable: ADHD symptomsScientific e
Page 81 and 82: Variable: Internalized symptomsScie
Page 83 and 84: The scientific evidence about the e
Page 85 and 86: Variable: Social skillsScientific e
Page 87 and 88: 7.1.4. How effective is the psychol
Page 89 and 90: 7.2. Psychopedagogical TreatmentQue
Page 91 and 92: • Working on habits that foster a
Page 93 and 94: Teacher’s adaptationsScientific e
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Scientific evidenceThere is not suf
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7.3. Pharmacological treatmentQuest
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to proteins is 15% and there are no
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AtomoxetineThis is a non-stimulant
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7.3.2. In ADHD: What pharmacologica
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There is strong scientific evidence
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Variable: Behavioural problemsScien
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There is not sufficient scientific
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BupropionThe NICE CPG</stro
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Summary of the scientific evidence
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7.3.4. In ADHD: When and with what
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MethylphenidateSummary of the scien
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AtomoxetineSummary of the scientifi
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The consensus of the American Heart
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In a RCT that studied the efficacy
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7.3.13. What scientific evidence ex
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7.3.15. Does the efficacy of pharma
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Recommendations 7.3.17.1. 7.3.17.2.
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Scientific evidenceThe scientific e
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There is limited scientific evidenc
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The combined intervention of MTA is
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There is limited scientific evidenc
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The scientific evidence of Zupancic
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RecommendationsC 7.5.1.1.The use of
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Summary of the scientific evidenceT
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Summary of the scientific evidenceT
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Elimination interventions include t
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Auditory stimulationThis is based o
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8. PreventionGiven the mainly genet
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Recommendations 9.1.1.In the specif
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Recommendations 9.4.1.Applicableleg
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10. Diagnostic and therapeutic stra
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Algorithm 3. Pharmacological treatm
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11. Dissemination and implementatio
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12. Future research recommendations
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home, at school or in the recreatio
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Appendix 1: Evidence levels and rec
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Impulsivitya) Often blurts out answ
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Appendix 3. Information for patient
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3. How does ADHD evolve with age?In
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5.1. Psychological treatment for AD
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What drugs are available in Spain?A
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Is pharmacological treatment for AD
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10. What can be done from school to
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Appendix 4. GlossaryAGREE: Instrume
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and mental operations, self-regulat
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tions that are to be compared.The r
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Appendix 5. AbbreviationsAACAPAAPAD
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MAMFF_20mgMHSMSCAMTA StudyNICENIMHN
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Appendix 6. Declaration of interest
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Alicia Koplowitz Foundation, Jansse
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Health Care Guideline: Diagnosis an
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Attention deficit hyperactivity dis
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tionario de Conners en nuestro medi
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50. Quinn P, Wigal S. Perceptions o
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twin study: preliminary report. 199
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Number 3, August 1999. Agency for H
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controlled trial of integrated home
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Improvement. Clinical Practice Guid
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Adolesc Psychiatry. 2006 Nov;45(11)
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Acad Child Adolesc Psychiatry. 1995
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omized, double-blind, placebo-contr
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300. Wilens TE, Newcorn JH, Kratoch
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functioning pervasive developmental
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P.V.P.: 10 €MINISTERIODE SANIDAD,
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CPG on ADHD

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