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.

Differences in biomarkers of crack-cocaine adolescent users before/after abstinence.

AIMS: To measure the variation in Brain-Derived Neurotrophic Factor (BDNF), Thiobarbituric Acid Reactive Substances (TBARS) and interleukin (IL) levels in crack-cocaine dependent adolescents after 21days of abstinence, comparing to levels found in a group of healthy controls. DESIGN: Cross-sectional nested on a short follow-up study. SETTING: Two inpatient treatment units for adolescents, and a low-income neighborhood. PARTICIPANTS: 90 adolescents, of both genders, with diagnosis of crack cocaine dependence, and 81 healthy adolescents. MEASUREMENTS: Serum levels of IL-6, IL-10, TBARS and BDNF were assessed on admission and discharge. Drug addiction severity was assessed by the Addiction Severity Index - Teen Version (T-ASI) and Cocaine Craving Questionnaire - Brief version (CCQ-b). Psychiatric comorbidities were assessed by the Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime Version (K-SADS-PL). Generalized Estimating Equations (GEE) were used to estimate the IL-6, IL-10, TBARS and BDNF levels, adjusted for confounders. Hedges' g was used to estimate effect size. FINDINGS: TBARS (p=0.005, d=0.04), IL-6 (p=0.027, d=0.40) and IL-10 (p=0.025, d=0.41) were elevated and BDNF (p<0.001, d=0.62) was reduced (p<0.001), in patients, in comparison to controls, at admission time. Variation in those levels between admission and discharge were not significant. CONCLUSIONS: Crack-cocaine use seems to be associated with inflammatory and oxidative imbalances in adolescents.

Predictors of early relapse among adolescent crack users.

Relapse is associated with a poor prognosis among drug users. Crack cocaine users are more prone to severe dependence because of the intensity of use. Additionally, initiating drug use during adolescence worsens users' prognosis due to the increased rates of impulsivity and other risk behaviors. This study aimed to identify the predictors of early relapse among adolescent crack users discharged from inpatient treatment. A cohort study was conducted with 89 psychiatric inpatients aged 12-17 years from two different hospitals in southern Brazil who met the criteria for crack abuse or dependence. Demographic data, substance use disorders, psychiatric comorbidities, and crack consumption profile were assessed during hospitalization using the Teen Addiction Severity Index, Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime, and Crack Consumption Profile. Participants were re-assessed at 1 and 3 months after hospital discharge to determine their crack cocaine use based on self-report, family/caregiver information, and urine tests, whenever possible. There were extremely high rates of relapse (valid percent) in the first and third months, 65.9 and 86.4%, respectively. Statistically significant associations were observed between relapse in the first month and length of cocaine/crack cocaine use, and length of hospital stay. Data at 3 months were not analyzed because of the small number of patients who did not relapse. The high rates and significant associations found in this study suggest that intensive outpatient treatment strategies targeting this population should be developed and implemented to prevent early relapse after detoxification. One of the possible approaches, based on recent studies, might explore motivation as a strategy to reduce the rate of early relapse.

Effects of crack cocaine addiction and stress-related genes on peripheral BDNF levels.

This study examined the effects of glucocorticoid receptor (NR3C1), corticotropin-releasing hormone receptor 1 (CRHR1), and brain-derived neurotrophic factor (BDNF) genes on susceptibility to crack cocaine addiction and BDNF levels. Crack addicted patients who sought treatment (n = 280) and non-addicted individuals (n = 241) were assessed. Three SNPs in NR3C1 (rs6198, rs41423247, and rs10052957), three in CRHR1 (rs12944712, rs110402, and rs878886), and one in BDNF (rs6265) were genotyped. No significant effect was seen in the case-control analyses. Crack cocaine addicted patients showed significantly lower serum BDNF levels. Significant effects were observed for NR3C1 rs41423247 and rs10052957. These effects were restricted to non-addicted individuals and they were supported by significant gene-by-disease status interactions. For CRHR1, all SNPs were associated with BDNF levels. Although there were significant effects only in the analysis restricted to non-addicted individuals, the lack of significant results in the gene-by-disease status interaction analyses suggest a general effect on BDNF levels. The haplotype analyses presented the same effect seen in the single marker analyses. This study suggests that SNPs in the NR3C1 and CRHR1 genes may influence BDNF levels, but this effect is blunted in the context of crack cocaine addiction. Therefore, our data may be interpreted in light of several studies showing pronounced effects of crack cocaine on BDNF levels. Since peripheral BDNF is a biomarker for several psychiatric phenotypes, our results may be useful in interpreting previous associations between stress-related SNPs, drug addiction, and depression.

Identification and initial management of intoxication by alcohol and other drugs in the pediatric emergency room / Identificação e manejo inicial de intoxicações por álcool e outras drogas na sala de emergência pediátrica

Abstract 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.

Resumo Objetivo: Revisar o rastreamento, o diagnóstico, a abordagem e o tratamento das intoxicações por álcool e outras drogas de crianças e adolescentes no contexto de emergência. Fontes dos dados: Foi feita uma revisão narrativa da literatura. Sumário dos achados: A detecção desse problema na sala de emergência pode ser um desafio, especialmente quando sua avaliação não é padronizada. O uso intencional e em grandes quantidades episódicas de substâncias psicoativas é o padrão em adolescentes e a intoxicação não intencional é mais comum em crianças menores de 12 anos. O quadro clínico em adolescentes e em crianças difere dos adultos e algumas particularidades são importantes no contexto de emergência. Após o manejo do quadro agudo, intervenções com vistas ao adolescente de risco podem ser efetivas. Conclusão: O diagnóstico e o tratamento das intoxicações por álcool e outras drogas em adolescentes e crianças em emergência requer uma avaliação sistemática do uso dessas drogas. Há poucos tratamentos específicos para intoxicação e o manejo é de apoio e das complicações clínicas relacionadas.

High rates of relapse in adolescents crack users after inpatient clinic discharge / Alto índice de recaída em adolescentes usuários de crack após a alta da internação

ABSTRACT Objective The objective of the present study was to evaluate 88 adolescent crack users referred to hospitalization and to follow them up after discharge to investigate relapse and factors associated with treatment. Methods Cohort (30 and 90 days after discharge) from a psychiatric hospital and a rehab clinic for treatment for chemical dependency in Porto Alegre between 2011 and 2012. Instruments: Semi-structured interview, conducted to evaluate the sociodemographic profile of the sample and describe the pattern of psychoactive substance use; Crack Use Relapse Scale/CURS; Questionnaire Tracking Users to Crack/QTUC; K-SADS-PL. Results In the first follow-up period (30 days after discharge), 65.9% of participants had relapsed. In the second follow-up period (90 days after discharge), 86.4% of participants had relapsed. Conclusion This is one of the first studies that show the extremely high prevalence of early relapse in adolescent crack users after discharge, questioning the cost/benefit of inpatient treatment for this population. Moreover, these results corroborate studies which suggested, young psychostimulants users might need tailored intensive outpatient treatment with contingency management and other behavioral strategies, in order to increase compliance and reduce drug or crime relapse, but this specific therapeutic modality is still scarce and must be developed in Brazil.

RESUMO Objetivo O objetivo do presente estudo foi avaliar 88 adolescentes usuários de crack no que se refere à hospitalização e dar-lhes seguimento após a alta, para investigar as recaídas e os fatores associados ao tratamento. Métodos Coorte (30 e 90 dias após a alta) de um hospital psiquiátrico e uma clínica de reabilitação, para o tratamento de dependência química em Porto Alegre, entre 2011 e 2012. Instrumentos: entrevista semiestruturada, realizada para avaliar o perfil sociodemográfico da amostra e descrever o padrão de uso de substâncias psicoativas; Escala de Recaída dos Usuários de Crack/ERUC; Questionário de Seguimento de Usuários de Crack/QSUC; K-SADS-PL. Resultados No primeiro período de seguimento (30 dias após a alta), 65,9% dos participantes recaíram. No segundo período de seguimento (90 dias após a alta), 86,4% dos participantes tiveram recaíram. Conclusão Este é um dos primeiros estudos que mostram a prevalência extremamente alta de recaída precoce em adolescentes usuários de crack após a alta, questionando o custo-benefício do tratamento em regime de internação para essa população. Além disso, esses resultados corroboram estudos que sugerem que usuários de psicoestimulantes jovens podem precisar de um adaptado Tratamento Ambulatorial Intensivo, com manejo de contingências e outras estratégias comportamentais, a fim de aumentar a adesão, reduzir o uso da droga ou recaída ao crime. No entanto, essa modalidade terapêutica específica ainda é escassa e deve ser desenvolvida no Brasil.

Crack Cocaine Use in Adolescents: Clinical Characteristics and Predictors of Early Initiation.

OBJECTIVE: To describe the clinical characteristics of adolescents with crack cocaine dependence and possible predictors of transition from drug experimentation to crack cocaine dependence. METHODS: This cross-sectional study enrolled a consecutive sample of 90 adolescents admitted to a psychiatric inpatient unit in the city of Porto Alegre in southern Brazil for crack cocaine detoxification between May 2011 and November 2012. Comorbid psychological conditions were assessed using the Kiddie-SADS-Present and Lifetime Version, and severity of drug use was assessed using the Teen Addiction Severity Index (T-ASI). Comorbidities were compared with those in a community sample of non-drug using controls (n = 81). RESULTS: Patients' mean age was 15.6 years (85.6% boys, 14.4% girls). Seventy-nine (93.2%) met criteria for cocaine dependence (DSM-IV-TR), while 78 (91.8%) had symptoms consistent with cocaine abuse. All patients had experimented with at least 1 other addictive substance before crack cocaine: 61.4%, tobacco (mean age at first use = 11.61 years); 44.3%, alcohol (age at first use = 12.43 years); and 54.5%, cannabis (age at first use = 12.15 years). Patients had used crack cocaine 23.2 days in the last month, and the mean age at first use of crack cocaine was 13.38 years. The most common psychiatric comorbidity was conduct disorder (81.8%), followed by oppositional defiant disorder (52.3%) and attention-deficit/hyperactivity disorder (44.3%), all of which were more prevalent in the patient population than in controls (P < .001). The T-ASI questionnaire showed severe consequences of drug use in most areas of life assessed. The mean time between onset of drug experimentation and crack cocaine dependence was 2.53 (SD = 1.96) years. When Cox regression models were applied, we found that predictors of earlier progression to using crack cocaine were age at first use of any drug (hazard ratio [HR] = 0.79 [95% CI, 0.71-0.88]; P < .001) and age at admission (HR = 0.7 [95% CI, 0.57-0.87]; P = .001). CONCLUSIONS: Patients were found to have a multitude of comorbid conditions, which supports the idea of treatment by a multidisciplinary health care team. For each year of delay in the age at first drug use, the chance of crack cocaine initiation is reduced by 18%. Prevention programs aimed at delaying experimentation with addictive substances, especially "gateway" drugs, could delay the progression to crack cocaine dependence.

IL-6 and IL-10 levels in the umbilical cord blood of newborns with a history of crack/cocaine exposure in utero: a comparative study.

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.

IL-6 and IL-10 levels in the umbilical cord blood of newborns with a history of crack/cocaine exposure in utero: a comparative study / 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 versus2.323,03, 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.

Cost-utility analysis of methylphenidate treatment for children and adolescents with ADHD in Brazil

Objective: To perform a cost-utility analysis on the treatment of attention deficit hyperactivity disorder (ADHD) with methylphenidate immediate-release (MPH-IR) in children and adolescents from Brazil. Method: A Markov model was constructed to compare MPH-IR vs. no treatment. A 24-week naturalistic study was conducted to collect transition probabilities and utility data. Effectiveness was expressed as quality-adjusted life-years (QALY), and costs reported in 2014 international dollars (I$). The perspective was the Brazilian Unified Health System as payer, and the time horizon was 6 years. Results: Of 171 patients, 73 provided information at baseline, and 56 at week 24. Considering the MPH-IR monthly cost of I$ 38, the incremental cost-effectiveness ratio (ICER) of treatment was I$ 9,103/QALY for children and I$ 11,883/QALY for adolescents. In two-way sensitivity analysis, considering one Gross National Product per capita (I$ 11,530) as willingness-to-pay, a cost of no-treatment lower than I$ 45/month would render MPH-IR a cost-saving strategy. Discussion: MPH-IR treatment of children and adolescents is cost-effective for ADHD patients from the Brazilian public health system perspective. Both patients and the healthcare system might benefit from such a strategy. Trial registration number: NCT01705613.

Cost-utility analysis of methylphenidate treatment for children and adolescents with ADHD in Brazil.

OBJECTIVE: To perform a cost-utility analysis on the treatment of attention deficit hyperactivity disorder (ADHD) with methylphenidate immediate-release (MPH-IR) in children and adolescents from Brazil. METHOD: A Markov model was constructed to compare MPH-IR vs. no treatment. A 24-week naturalistic study was conducted to collect transition probabilities and utility data. Effectiveness was expressed as quality-adjusted life-years (QALY), and costs reported in 2014 international dollars (I$). The perspective was the Brazilian Unified Health System as payer, and the time horizon was 6 years. RESULTS: Of 171 patients, 73 provided information at baseline, and 56 at week 24. Considering the MPH-IR monthly cost of I$ 38, the incremental cost-effectiveness ratio (ICER) of treatment was I$ 9,103/QALY for children and I$ 11,883/QALY for adolescents. In two-way sensitivity analysis, considering one Gross National Product per capita (I$ 11,530) as willingness-to-pay, a cost of no-treatment lower than I$ 45/month would render MPH-IR a cost-saving strategy. DISCUSSION: MPH-IR treatment of children and adolescents is cost-effective for ADHD patients from the Brazilian public health system perspective. Both patients and the healthcare system might benefit from such a strategy. TRIAL REGISTRATION NUMBER: NCT01705613.

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. .

Tratamento psicoterápico para adolescentes usuários de substâncias psicoativas / 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 adolescentes.(AU)

The 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.(AU)

Do phenotypic characteristics, parental psychopathology, family functioning, and environmental stressors have a role in the response to methylphenidate in children with attention-deficit/hyperactivity disorder? A naturalistic study from a developing country.

Little is known about the effect of clinical characteristics, parental psychopathology, family functioning, and environmental stressors in the response to methylphenidate in children with attention-deficit/hyperactivity disorder (ADHD) followed up in a naturalistic setting. Data from cultures outside the United States are extremely scarce. This is a longitudinal study using a nonrandom assignment, quasi-experimental design. One hundred twenty-five children with ADHD were treated with methylphenidate according to standard clinical procedures, and followed up for 6 months. The severity of ADHD symptoms was assessed by the Swanson, Nolan, and Pelham rating scale. In the final multivariate model, ADHD combined subtype (P < 0.001) and comorbidity with oppositional defiant disorder (P = 0.03) were both predictors of a worse clinical response. In addition, the levels of maternal ADHD symptoms were also associated with worse prognosis (P < 0.001). In the context of several adverse psychosocial factors assessed, only undesired pregnancy was associated with poorer response to methylphenidate in the final comprehensive model (P = 0.02). Our study provides evidence for the involvement of clinical characteristics, maternal psychopathology, and environmental stressors in the response to methylphenidate. Clinicians may consider adjuvant strategies when negative predictors are present to increase the chances of success with methylphenidate treatment.

Smoking during pregnancy and attention-deficit/hyperactivity disorder, predominantly inattentive type: a case-control study.

OBJECTIVE: Few previous studies assessed specifically attention-deficit/hyperactivity disorder, predominantly inattentive subtype (ADHD-I) in nonreferred samples. This study investigated the association between ADHD-I and prenatal exposure to nicotine. METHOD: In a case-control study performed between September 2002 and April 2005, we assessed a nonreferred Brazilian sample of 100 children and adolescents with ADHD-I and 100 non-ADHD controls (6-18 years old). Cases and controls, matched by gender and age, were screened using teacher reports in the Swanson, Nolan, and Pelham-IV (SNAP-IV) scale. They were systematically evaluated through structured diagnostic interviews. Prenatal exposure to nicotine and potential confounding factors were evaluated by direct interview with mothers. RESULTS: Adjusting for confounding factors (maternal ADHD, oppositional defiant disorder, birth weight, and alcohol use during pregnancy), children whose mothers smoked>or=10 cigarettes per day during pregnancy presented a significantly higher odds ratio for ADHD-I than children who were not exposed to nicotine during pregnancy (odds ratio 3.44; 95% confidence interval 1.17-10.06). Dimensional analyses showed significantly higher inattentive scores in subjects whose mothers smoked>or=10 cigarettes per day than in others after adjusting for confounding factors (p=.002). CONCLUSIONS: In a nonreferred sample, the authors expanded to ADHD-I previous findings documenting the association between prenatal exposure to nicotine and broadly defined ADHD in clinical samples.

Association between alpha-2a-adrenergic receptor gene and ADHD inattentive type.

BACKGROUND: Previous investigations have demonstrated that an MspI polymorphism at the adrenergic alpha2A receptor gene (ADRA2A) is associated with severity of attention-deficit/hyperactivity disorder (ADHD) inattentive symptoms in clinical samples composed mainly of subjects with ADHD, combined type. This study aimed to investigate the association between this ADRA2A polymorphism and attention-deficit/hyperactivity disorder-inattentive type (ADHD-I) in a nonreferred sample. METHODS: In a case-control study, we assessed a sample of 100 children and adolescents with ADHD-I and 100 non-ADHD controls. Cases and controls were matched by gender and age and were screened by using teacher reports in a revised version of the Swanson, Nolan, and Pelham rating scale at 12 schools. Psychiatric diagnoses were derived through structured diagnostic interviews. RESULTS: Homozygous subjects for the G allele at the ADRA2A had significantly higher odds ratio (OR) for ADHD-I than did those with other genotypes (CC + CG genotypes), even after adjusting for potential confounders (p = .02; OR = 3.78; 95% confidence interval = 1.23-11.62). In family-based analyses, no significant associations were detected. CONCLUSIONS: Our results suggest that the ADRA2A may be associated with ADHD-I, replicating previous findings from clinical samples that have suggested the importance of this gene for the dimension of inattention. In addition, these results support the role of the noradrenergic system in ADHD.

Interrater agreement for the schedule for affective disorders and schizophrenia epidemiological version for school-age children (K-SADS-E).

OBJECTIVE: The main objective of this study was to assess the interrater agreement for the Schedule for Affective Disorders and Schizophrenia Epidemiological version for School-Age Children (K-SADS-E). METHODS: Four interviewers being trained with the K-SADS-E scored independently 29 videotaped interviews performed with psychiatric outpatients in the ADHD Outpatient Clinic at Hospital de Clínicas de Porto Alegre. Interrater agreement analysis was performed using the kappa coefficient (k). RESULTS: Kappa coefficients were.93 (p<.001) for affective disorders,.9 (p<.001) for anxiety disorders,.94 (p<.001) for attention-deficit/hyperactivity disorders and disruptive behavior disorders. CONCLUSION: These findings suggest an excellent interrater agreement for the diagnosis of several mental disorders in childhood and adolescence by the Brazilian Portuguese version of the K-SADS-E.

Interrater agreement for the schedule for affective disorders and schizophrenia epidemiological version for school-age children (K-SADS-E)

OBJETIVE: The main objective of this study was to assess the interrater agreement for the Schedule for Affective Disorders and Schizophrenia Epidemiological version for School-Age Children (K-SADS-E). METHODS: Four interviewers being trained with the K-SADS-E scored independently 29 videotaped interviews performed with psychiatric outpatients in the ADHD Outpatient Clinic at Hospital de Clínicas de Porto Alegre. Interrater agreement analysis was performed using the kappa coefficient (k). RESULTS: Kappa coefficients were .93 (p<.001) for affective disorders, .9 (p<.001) for anxiety disorders, .94 (p<.001) for attention-deficit/hyperactivity disorders and disruptive behavior disorders. CONCLUSION: These findings suggest an excellent interrater agreement for the diagnosis of several mental disorders in childhood and adolescence by the Brazilian Portuguese version of the K-SADS-E