الفهرس Only 14 pages are availabe for public view
 |  | from | 294 |  |  |
| | | from | 294 | | |
Abstract
Evidence Based Medicine (EBM): is ”The process of systematically finding, appraising and using contemporaneous research findings as the basis for clinical decisions”, and described as ”partly a philosophy, partly a skill, and partly the application of a set of tools”. EBM places great emphasis on patient preference and values and encourage patient-centered care.
To conduct the EBM it should process 5 steps: formulate the question, search for answer, appraise the evidence, apply the result to this patient, and assess the outcome. As it can use some shortcut to get the evidence from previously answered question, Critically Appraised Topics (CAT), and Clinical informatics service.
Randomized Controlled Trial (RCT) is regarded as the gold standard trial for evaluating the effectiveness of interventions. Blinding is the most common method used to minimize observer bias in RCTs.
Conflicting results from RCTs can be avoided through systematic review, Cochrane systematic reviews is the pioneer due to minimizing bias, thus providing more reliable findings from which conclusions can be drawn and decisions made.
It is a common misconception that evidence-based medicine is a thinly veiled attempt to ration healthcare. Regardless of the kind of research evidence being applied, the clinical experience of well trained physicians and psychologists is essential in formulating practice relevant research (evidence generation), evidence reviews, guidelines for practice, and policies.
Evidence-based medicine (EBM) is neither old-hat nor impossible to practice; EBM is not ”cook-book” medicine; EBM is not restricted to randomized trials and meta-analyses.
There is increasing concern that technologies for treating child & adolescent mental health disorders be evidence-based, so it can be measure the attitude of child psychiatrist to EBM through [The Evidence-Based Practice Attitude Scale (EBPAS)].
In the U.S. the National Survey of prevalence of ADHD report describes the results of that analysis, which indicated that, in 2003, approximately 4.4 million children aged 4-17 years were reported to have a history of ADHD diagnosis; of these, 2.5 million (56%). There is no appropriate definition of adult ADHD.
There was strong evidence for clustering of inattentive and hyperactive-impulsive symptoms in both population and clinical samples.
There are gender disparities male-to-female prevalence rates of 2.5 to 1, while clinic populations show the ratio as high as 10 to 1. There is strong evidence for continuity of ADHD symptoms over the lifespan.
Evidence is established for association of ADHD with allelic variants of the dopamine β-hydroxylase (DBH) and dopamine receptor D2 (DRD2) genes. The Executive Dysfunction theory and other theories cannot be said to explain all of the symptoms of ADHD, for future progress, the studies on aspects of executive functioning in ADHD aim to state explicitly a falsifiable hypothesis.
In the most studies, the psychological interventions of ADHD were broadly based on CBT principles; Evidence regarding incremental benefits of Behavior Therapy (BT) to medication has been controversial. Studies found that BT was not incrementally beneficial when optimal treatment effects had already been obtained with higher dosages of methylphenidate as (MTA Cooperative Group).
Psychological/behavioural treatment versus standard care: no significant difference between psychological/behavioural treatment and standard care (medication, psychological therapy, or both, as provided by the community health provider).
Parent plus teacher training versus parent training alone: There is one small RCT found that a combination of parent training and teacher education significantly improved symptoms of ADHD.
The effects of combination treatments for ADHD in children and adolescents: Compared with control/ placebo Methylphenidate plus psychological/ behavioural treatment may be more effective at improving parent ratings (Conners Parent’s Rating Scale) of ADHD.
Compared with methylphenidate alone Methylphenidate plus multimodal psychological treatment (including parent training and counseling, social-skills training, psychological therapy and academic assistance) may be more effective at improving patient-rated SSRS (Social Skills Rating Scale) (very low-quality evidence ).
Compared with psychological/ behavioural treatments alone Methylphenidate plus behavioural treatments may be more effective at improving ADHD behaviors and symptoms in children aged 5–18 years, but not social skills or measures of parent-child relationships (very low-quality evidence).
In the absence of evidence that psychological interventions have a positive effect on teacher ratings of ADHD symptoms and conduct behaviour, the evidence of beneficial effects based on ratings by parents should be interpreted with some caution. Parent ratings may be potentially subject to bias because in trials of psychological interventions for children with ADHD that do not use a control intervention, parents will know whether they and/or their child has received the intervention.
The quality of the evidence included in this review was variable and lacked any ‘gold standard’ because no diagnostic tests for ADHD have been developed or tested.
In the absence of a gold standard for the validity of diagnosis of ADHD or hyperkinetic disorder a lower level of evidence was included in this review.
Pharmacological intervention of ADHD:
Atomoxetine:
Compared with placebo Atomoxetine is more effective at improving ADHD symptoms (assessed using Attention Deficit Hyperactivity Disorder Rating Scale [ADHD-RS]) in children and adolescents aged 6–18 years (moderate quality evidence) in symptoms severity.
Compared with methylphenidate Atomoxetine and low doses of methylphenidate seem equally effective at 8 weeks at improving response rates in children and adolescents aged 6–16 years (moderate-quality evidence).
Compared with placebo Atomoxetine may be no more effective at 7 weeks at improving academic productivity in children and adolescents aged 8–12 years as assessed using the Academic Performance Rating Scale (low-quality evidence).
Atomoxetine has been associated with decreased appetite, nausea, vomiting, somnolence, suicidal ideation, depression, height and weight changes, liver disease, and seizures.
Dexamfetamine Sulphate:
Compared with placebo Dexamfetamine (dexamphetamine) may be more effective at improving hyperactivity and ADHD symptoms as measured by abbreviated Conners Teacher’s Rating Scale (very low-quality evidence ).
Compared with dexamfetamine sulphate plus clonidine Adding clonidine to dexamfetamine regimens may be more effective at improving response rates for conduct symptoms but not for hyperactivity, in children with comorbid oppositional defiant disorder or conduct disorder (very low-quality evidence).
Compared with methylphenidate unknown whether dexamfetamine is more effective at improving ADHD symptoms in children and adolescents aged 5–18 years (very low-quality evidence).
Methylphenidate:
Compared with placebo Methylphenidate (including trans-dermal formulations) may be more effective at reducing core symptoms of ADHD in children aged 5–18 years (low-quality evidence).
Compared with atomoxetine Low doses of methylphenidate and atomoxetine seem equally effective at improving response rates at 8 weeks in children and adolescents aged 6–16 years (moderate-quality evidence).
Compared with dexamfetamine unknown whether methylphenidate is more effective at improving ADHD symptoms in children and adolescents aged 5–18 years (very low-quality evidence).
Compared with clonidine unknown whether methylphenidate is more effective at reducing severity of ADHD symptoms in children aged 7–14 years with comorbid chronic tic disorders (very low-quality evidence).
Compared with methylphenidate plus clonidine Methylphenidate plus clonidine may be no more effective at reducing severity of ADHD symptoms in children aged 7–14 years with comorbid chronic tic disorders and may increase the risk of bradycardia (very low-quality evidence).
Compared with psychological/behavioural treatment unknown whether methylphenidate is more effective at improving ADHD symptoms in children and adolescents aged 5–18 years (very low-quality evidence).
Compared with methylphenidate plus psychological/ behavioural treatment Methylphenidate plus multimodal psychological treatment (including parent training and counseling, social-skills training, psychological therapy and academic assistance) may be more effective at improving patient-rated SSRS (Social Skills Rating Scale) at 1 year, but not other parent or teacher rating scales in children aged 7–9 years (very low-quality evidence).
Methylphenidate plus clonidine compared with clonidine alone Methylphenidate plus clonidine plus may be no more effective at reducing severity of ADHD symptoms in children aged 7–14 years with comorbid chronic tic disorders, and may increase the risk of bradycardia (very low-quality evidence).
School performance:
Compared with placebo Methylphenidate may be more effective at improving attention at 12 hours and at increasing attempts at and increasing correct completion of mathematical problems at 8 hours (low-quality evidence).
Compared with methylphenidate plus psychological/ behavioural treatment Methylphenidate plus multimodal psychological treatment (including parent training and counselling, social-skills training, psychological therapy and academic assistance) may be no more effective at improving academic performance scores (Stanford Achievement Tests in total reading, math computation, and listening comprehension) at 1 year in children aged 7–9 years (very low-quality evidence).
Adverse effects:
Methylphenidate has been associated with decreased appetite, insomnia, stomach ache, and decrease in growth rate affecting height and weight.
Clonidine
There is evidence that clonidine reduces children’s ADHD core symptoms and conduct problems as well as producing general clinical improvement.
Special circumstances – ADHD comorbid with Tourette’s syndrome, chronic motor tic or chronic vocal tic disorder.
Bupropion
There is no evidence that bupropion is effective in reducing ADHD core symptoms or conduct problems in children with ADHD. There is limited evidence that bupropion may increase the risk of rash.
There is some evidence that bupropion is effective in reducing ADHD core symptoms and producing clinical improvement in adults with ADHD.
Omega-3 polyunsaturated fatty acid compounds (fish oils)
Compared with placebo Food supplemented with long-chain omega-3 polyunsaturated fatty acids may be no more effective than foods containing olive oil at improving severity of symptoms of ADHD in children aged 6–12 years.
Homeopathy
Compared with placebo: unknown whether homeopathic interventions are more effective at improving symptoms of ADHD at 12–18 weeks in children and adolescents aged 6–12 years.
There is no evidence support of antidepressant or anti-psychotic for treatment of ADHD.
Prevalence of Autism Spectrum Disorders
A recent U.S. study analyzing national survey data for 2007 of parents’ reports of ASDs indicated that approximately 1% of all children aged 3–17 years and 1.3% of all children aged 6–8 years had an ASD.
Thimerosal in MMR vaccine is not one of causes of ASD.
There is evidence of Corpus callosum reductions are present in autism and support the aberrant connectivity hypothesis through meta-analytical study of ten studies.
There are three diagnostic guidelines for ASD as Europe (Scottish Intercollegiate Guidelines Network), The National Autism Plan for Children (National Initiative for Autism), and North America (American Academy of Neurology and the Child Neurology).
Treatment of Autism Spectrum Disorders
Early Intensive Behavioural Interventions
Cognitive function:
Compared with other therapy Early intensive behavioural interventions may improve IQ and comprehension (very low-quality evidence).
Behavioural function:
Compared with other therapy Early intensive behavioural interventions may improve adaptive behaviour (very low-quality evidence).
Child’s Talk programme:
Social function
Compared with standard care The Child’s Talk programme may result in improvements in social interaction and language outcomes compared with existing care alone (moderate-quality evidence).
More than Words programme:
Social function
Compared with delayed treatment Children with autism and their parents who had undertaken a ”More Than Words” training course may have improved communication outcomes compared with parents and children who had delayed access to the course (very low-quality evidence).
There is consensus that Picture Exchange Communication System (PECS) is beneficial in the treatment of children with autism (very low-quality evidence).
TEACCH may improve psycho-educational scores in children with autism (very low-quality evidence).
(EarlyBird Programme); (FloorTime); (Portage Scheme); (Relationship-Development Intervention); (Social Skills Training); (Social Stories); (Cognitive Behavioural Therapy); (Facilitated Communication) and (Son-Rise) all the above programme have no supporting evidence.
There are no clinically important results about the effects of a gluten-free diet alone, or a casein-free diet alone, in children with autism.
Methylphenidate hydrochloride may slightly reduce hyperactivity in children with autism (low-quality evidence).
Risperidone is more effective at improving behaviour such as irritability, social withdrawal, stereotypy, hyperactivity, and inappropriate speech at 8 weeks in children with autism (moderate-quality evidence).
Secretin does not seem more effective in treating any of the symptoms of autism in children (moderate-quality evidence).
The American Academy of Pediatrics (1998) has suggested that auditory integration training should be used for research purposes only. Treatment with auditory integration training may involve high costs to the family.