注意缺陷多动障碍低觉醒模型的新证据

注意缺陷多动障碍(Attention Deficit Hyperactivity Disorder,ADHD)是儿童期常见的一种发展性的异常,其病因及发生机理至今未明。低觉醒模型是ADHD成因的一种假设。本文从睡眠障碍导致的低觉醒探讨ADHD发生机理。通过对ADHD儿童的睡眠障碍进行分析以及将ADHD外在表现与睡眠剥夺后的表现进行对比分析,得出ADHD儿童存在的低觉醒是由于外显的或内隐的睡眠障碍引起的,一方面间接证明了低觉醒模型,另一方面为ADHD的成因研究开拓了新的思路。     

注意缺陷多动障碍儿童睡眠障碍与铁缺乏关系 的临床研究

目的:探讨注意缺陷多动障碍(ADHD)患儿睡眠障碍与血清铁蛋白水平的关系。方法:符合美国精神疾病诊断与统计手册第4版(DSM-Ⅳ)中ADHD诊断标准的62例6-14岁ADHD患儿,由ADHD患儿的父母填写睡眠障碍量表(SDSC),检测ADHD患儿的血清铁蛋白水平。结果:与血清铁蛋白水平高于45μg/L的ADHD患儿相比较,血清铁蛋白水平低于45μg/L的ADHD患儿的SDSC"睡眠醒觉转换障碍"项评分和总分明显高于前者(P<0.05)。2组间其他项评分比较无显著性差异(P>0.05)。SDSC"睡眠醒觉转换障碍"项评分与血清铁蛋白水平成负相关(P<0.05)。结论:血清铁蛋白水平低于45μg/LADHD患儿SDSC"睡眠醒觉转换障碍"(睡眠中的异常运动)的危险性显著增加。     

注意缺陷多动障碍儿童睡眠障碍与铁缺乏关系的临床研究

目的：探讨注意缺陷多动障碍（ADHD）患儿睡眠障碍与血清铁蛋白水平的关系。方法：符合美国精神疾病诊断与统计手册第4版（DSM-Ⅳ）中ADHD诊断标准的62例6．14岁ADHD患儿,由ADHD患儿的父母填写睡眠障碍量表（SDSC）,检测ADH-D患儿的血清铁蛋白水平。结果：与血清铁蛋白水平高于45／μg／L的ADHD患儿相比较,血清铁蛋白水平低于45／μg／L的ADHD患儿的SDSC“睡眠醒觉转换障碍”项评分和总分明显高于前者（P〈0．05）。2组间其他项评分比较无显著性差异（P〉0．05）。SDSC“睡眠醒觉转换障碍”项评分与血清铁蛋白水平成负相关（P〈0．05）。结论：血清铁蛋白水平低于451μg／LADHD患儿SDSC“睡眠醒觉转换障碍”（睡眠中的异常运动）的危险性显著增加。     

儿童学业压力居住环境与睡眠障碍关系分析

目的 了解武汉市学龄儿童睡眠障碍发生情况及与学业压力、居住环境的关系,为相关政策制定提供依据.方法 在武汉市4个行政区各随机抽取1所小学的一～六年级所有健康儿童,由专人负责对其家长进行儿童睡眠状况问卷调查.结果 学龄儿童睡眠障碍报告率为71.9％,睡眠焦虑报告率最高为38.0％,其次是夜间磨牙为30.0％.课业负担重、读书感到有压力、学习成绩偏下的学龄儿童睡眠障碍发生率高,差异有统计学意义.居室夜间周围环境、儿童有无独立的卧房、儿童是否有自己的床、儿童平时或周末看电视时间对学龄儿童睡眠障碍发生均有较大影响.结论 课业负担重、读书感到有压力的学龄儿童更容易发生睡眠障碍,社会各界应对学龄儿童的睡眠障碍给予足够重视.     

长沙市2～12岁哮喘儿童睡眠紊乱研究

目的:对长沙市2～12岁非哮喘儿童及哮喘儿童睡眠状况进行调查,比较常见睡眠障碍在两组中的发生率区别.方法:于2006年6月至10月对长沙市五个区的小学及幼儿园采取整群随机抽样方法进行调查抽取2～12岁健康儿童3420例及湘雅二院儿童哮喘专科门诊随机抽取2～12岁符合哮喘诊断标准[6]的哮喘儿童248名进行问卷调查,由专业人员指导家长填写.结果:哮喘儿童睡眠障碍发生率58%,显著高于健康儿童组38%水平.哮喘儿童中,每周1～3次以上打鼾的32例(12.9%),喉头哽咽的5例(2%),呼吸暂停的3例(1.2%),辗转不安的36例(14.5%),用口呼吸30例(12.1%),多汗97例(39.1%),肢体抽动18例(7.3%),磨牙34例(13.7%),说梦话12例(4.8%),梦游2例(0.8%),夜间尿床11例(4.4%),觉醒憋醒8例(3.2%),夜间清醒6例(2.4%),入睡过早5例(2%),易惊醒10例(4%),尖叫哭喊6例(2.4%).其中,每周1～3次以上打鼾、辗转不安、用口呼吸、多汗、肢体抽动、觉醒憋醒、易惊醒七项存在显著性差异(P＜0.05).结论:哮喘儿童睡眠障碍发生率显著高于健康儿童,应加强对哮喘儿童睡眠障碍的干预.     

营养性缺铁性贫血与注意缺陷多动障碍的临床关系研究——258例病例分析

目的:通过对营养性缺铁性贫血与注意缺陷多动障碍的病例研究,探讨两者之间的关系。方法:对258例NIDA的病因、临床表现和治疗进行临床分析,包括其中的31例中重度ADHD。结果:本组NIDA患儿病因主要为未及时添加富铁辅食、饮食结构不合理、消化道疾病、鼻衄等,临床主要表现为头晕、乏力、注意力不集中、记忆力减退等,对患者进行病因治疗以及服用生血宁片;ADHD的病因不明,临床表现为注意力不集中、活动过度、行为冲动等,通过综合治疗可以改善症状。NIDA的患儿ADHD的发病率较正常儿童为高。结论:NIDA与ADHD的关系密切。     

心内科住院患者睡眠质量分析与护理干预

目的:了解心内科住院患者睡眠质量,分析睡眠障碍的原因,探讨改善患者睡眠障碍的有效护理对策。方法:对我院2010年5月-2010年12月心内科109例住院睡眠障碍患者采取问卷调查及深入访谈相结合的方法进行调查,找出心内科患者睡眠障碍的原因;随后,将109例患者随机分为两组,对照组实行组常规护理,干预组实行有针对性的护理,7d后对对两组患者睡眠障碍进行测评。结果:心内科患者睡眠障碍症状为:入眠时间长,早醒,觉醒次数多,醒后再入眠难;睡眠障碍原因为:患者自身疾病、心理、环境、其他及综合因素所致。通过有针对性的护理干预后,两组有较大差距(P<0.05),干预组患者睡眠障碍改善明显,干预组好于对照组,表明护理干预可有效改善患者的睡眠质量。结论:疾病因素、心理因素以及生活习惯是影响心内科住院患者睡眠质量的主要因素,通过科学有效的护理干预措施,可以改善心内科患者的睡眠质量,提高患者的身心健康。     

失眠障碍与过度觉醒:来自静息态脑电和睡眠脑电的证据

失眠障碍已成为仅次于抑郁症的全球第二大流行性精神疾病.过度觉醒模型是解释失眠障碍维持机制的重要理论之一,而静息态脑电和睡眠脑电则为这一模型提供了最重要的证据支持.本文首先归纳了进行静息态和睡眠脑电分析的方法,并提出从清醒静息态、入睡到不同睡眠期的系统分析框架.通过分析前人的研究发现,失眠障碍过度觉醒的静息态和睡眠脑电证据主要有:睡眠连续性和宏观结构受损、觉醒增加、日间睡眠潜伏期延长、清醒和非快速眼动睡眠期脑电β活动的升高等.失眠的认知行为治疗、部分非苯二氮类药物、睡眠期的经颅直流电刺激等治疗手段,可显著降低患者的过度觉醒.脑电功率谱分析有助于区分不同的失眠障碍亚型,评估药物和非药物干预疗效,但在应用中应充分考虑年龄、性别、脑电频段划分等影响.未来的研究应进一步关注不同失眠障碍亚型的皮层过度觉醒,统一脑电频段划分标准,严格控制年龄、性别等因素的干扰.应在睡眠分期判读和功率谱分析的基础上,逐步推进源定位、时频、无标度等介观和微观结构的脑电分析,促进静息态脑电和睡眠脑电在失眠障碍诊断和治疗评估中的应用.     

昼夜节律系统与成人昼夜节律睡眠觉醒障碍

昼夜节律是存在于所有生命体中、接近24小时的内源性生物节律。昼夜节律与社会或环境节律的长期不同步,会引起睡眠、情绪等一系列变化。本文阐述了昼夜节律系统与睡眠之间的联系,重点介绍成人昼夜节律睡眠觉醒障碍疾病的临床研究成果,以期加强临床医生对该病的认识和诊治。     

注意缺陷多动障碍共患阅读障碍：认知-脑-基因的多维度研究进展

注意缺陷多动障碍(attention-deficit/hyperactivity disorder,ADHD)和发展性阅读障碍(developmental dyslexia,DD)是两种常见的神经发育性障碍,二者共患的比率高达25%～48%.本文拟从认知-脑-基因等多个维度对ADHD共患DD的研究进展进行综述. ADHD和DD共患的共同认知损害可能是加工速度缺陷,其作为内表型能够很好地帮助解释遗传因素如何通过影响认知功能进而导致出现ADHD共患DD的临床表型.而国内对ADHD共患DD的研究较少,已有的多项研究仅关注ADHD伴学习障碍,但缺乏标准的DD临床诊断标准.本文指出了统一诊断标准、结合多学科研究以及未来个体化训练的必要性.     

Sleep microstructure is not altered in children with attention-deficit/hyperactivity disorder (ADHD)

The high rate of occurrence of sleep disturbances in children with attention-deficit/hyperactivity disorder (ADHD) prompted the idea that structural and neurotransmitter changes might give rise to specific sleep pattern abnormalities. The aim of this study was to evaluate the microstructure of sleep in children with ADHD who had no polysomnographically diagnosed sleep disorder, had never been treated for ADHD, and were free from any psychiatric comorbidity. Participants were 14 patients with ADHD (12 boys and 2 girls aged 7-12 years, mean age 9.6+/-1.6). ADHD was diagnosed according to DSM-IV criteria (Diagnostic and statistical manual of mental disorders). Psychiatric comorbidities were ruled out by detailed psychiatric examination. The patients underwent two consecutive overnight video-polysomnographic (PSG) recordings, with the sleep microstructure (cyclic alternating pattern - CAP) scoring during the second night. The data were compared with age- and sex-matched controls. Sleep microstructure analysis using CAP revealed no significant differences between the ADHD group and the controls in any of the parameters under study. In conclusions, no ADHD-specific alterations were found in the sleep microstructure.     

Comorbid ADHD and mental health disorders: are these children more likely to develop reading disorders?

While attention-deficit/hyperactivity disorder (ADHD) has been associated with both internalizing and externalizing childhood behaviour disorders, the specific relationship of these comorbid disorders to ADHD and reading problems is less well defined. The present study analysed data from the Australian Twin ADHD Project, which utilized DSM-IV-based ratings of ADHD, separation anxiety disorder, generalized anxiety disorder, depression, conduct disorder, and oppositional defiant disorder for twins and siblings aged 6 to 18 years. While differences between children with and without ADHD were demonstrated for those with separation anxiety disorder, generalized anxiety disorder, depression, conduct disorder, oppositional defiant disorder and a reading disorder, for all age groups, regression analysis of ADHD diagnostic subtypes by age and reading disorder showed that only generalized anxiety disorder remained significant after controlling for ADHD subtypes. Analysis of the mean reading disorder scores in children with and without ADHD showed that children with conduct disorder had significantly more reading problems, as did children with multiple comorbid disorders. In summary, both age and ADHD diagnosis were associated with variations in these comorbid disorders, and multiple comorbid disorders were associated with greater reading impairment.     

ComorbiditéS associées au trouble déficit de l’attention avec hyperactivité : Données épidémiologiques et implications thérapeutiques

ADHD has become one of the most frequent cause of referrals for children’ behaviour disorders. ADHD is a prevalent psychiatric condition affecting 5% to 9% of school-age children with regards to DSM-IV R diagnostic criteria. In addition, according to the results of different epidemiological studies, patients with ADHD very often experience comorbid conditions in 50% to 90% of the cases. The most frequent comorbidities include externalised disorders, (oppositional defiant disorder, conduct disorders), learning disorders, internalised disorders (anxiety, depression) and tics (chronic motor tics, Tourette’s syndrome). Given their negative impact on the outcome of ADHD in terms of affective and social functioning, and of social and school adaptation, these comorbid conditions should be carefully and systematically searched, even without any actual complaint. Although management of comorbid psychiatric conditions is never simple nor straightforward, therapeutic option should be considered taking into consideration both management of ADHD and specificity of these comorbidities.     

The use of actigraphy in the monitoring of methylphenidate versus placebo in ADHD: a meta-analysis

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood. There is an increasing need to find objective measures and markers of the disorder in order to assess the efficacy of the therapy and to improve follow-up strategies. Actigraphy is an objective method for recording motor activity and sleep parameters using small, computerized, watch-like devices worn on the body, and it has been used in many clinical trials to assess methylphenidate efficacy and adverse effects in ADHD. Our article aim is to systematically review and perform a meta-analysis of the current evidence on the role of actigraphy in both the detection of changes in activity and in sleep patterns in randomized clinical trials that compared methylphenidate against placebo in the treatment of ADHD. A comprehensive literature search of PubMed/MEDLINE, Scopus, Embase, Cochrane Library, CINHAL and PsycINFO databases was carried out to find randomized clinical trials comparing methylphenidate versus placebo in children with ADHD, using actigraphic measures as an outcome. No start date limit was used and the search was updated until June 2013. The primary outcome measures were ‘total sleep time’ and daytime ‘activity mean’. As secondary outcomes, we analyzed ‘sleep onset latency’, ‘sleep efficiency’ and ‘wake after sleep onset’. Eight articles comprising 393 patients were included in the analysis. Children with ADHD using MPH compared to placebo have a significant difference of a large effect with a diminishing value in the activity mean. For the total sleep time, we found a significant and large effect in the decrease in sleep in MPH group. This study shows that MPH may effectively reduce mean activity in ADHD children, but it may negatively affect total sleep time.     

孟鲁斯特钠对儿童OSAHS治疗效果的初步研究

目的：探讨孟鲁斯特钠对儿童阻塞性睡眠呼吸暂停低通气综合征（obslructivesleepapneahypopneasyndrome,OSAHS）治疗疗效。方法：对经电子鼻咽喉镜检查腺样体Ⅲ、Ⅳ级经多导睡眠监测为OSAHS的儿童96例,分成两组：药物治疗组48例,使用孟鲁斯特钠,连续使用1个月以上;未用药物组48例。对其家长进行相关临床表现的问卷调查。结果：两组患儿在年龄、病程、伴有鼻部疾病情况以及临床问卷分值间均无显著性差异（P〉0．05）。3个月后随访情况为,药物治疗组经治疗后在“响鼾”、“不安宁的睡眠或频繁醒觉”、“鼻阻塞而张口呼吸”以及“鼻腔很多鼻涕”4个症状的改善有统计学差异（P〈0．05）。未用药物组随访前、后问卷调查,差异均不具有显著性（P〉0．05）。结论：孟鲁斯特钠对儿童OSAHS治疗有一定疗效,可先行药物治疗。症状仍无明显改善的再考虑选择手术治疗。     

儿童与成人阻塞型睡眠呼吸暂停低通气综合征代谢异常特征的比较

目的：探讨儿童及成人阻塞型睡眠呼吸暂停低通气综合症（OSAHS）发病原因、睡眠呼吸紊乱严重程度及合并代谢异常程度的差别。方法：对我院2003年1月1日至20]0年7月1日71例诊断为OSAHS住院患者进行回顾性调查,登记年龄、性男日、发病原因、血压、白细胞计数、中性粒细胞比率、淋巴细胞比率、呼吸暂停低通气指数（AHI）、夜间最低血氧饱和度、微觉醒指数。根据年龄进行分组,年龄〈18岁者为A组,年龄≥18岁者为B组。比较两组发病原因、睡眠呼吸紊乱及合并代谢异常程度的差剐。结果：1．A组慢性扁桃体炎和（或）腺样体肥大发生率明显高于B组（P〈O．01）,鼻中隔偏曲发生率明显低于B组（P〈0．01）。2．与B组比较,A组AHI及微觉醒指数降低,夜间最低血氧饱和度升高（P〈0．01）;3．与B组比较,A组高血压、中性粒细胞比率、谷丙转氨酶比例降低（P〈0．05）。结论：A组睡眠呼吸紊乱程度及代谢异常较B组程度轻,更需关注成人阻塞型睡眠呼吸暂停低通气综合症的综合治疗。     

Intolerance of uncertainty in children with attention-deficit/hyperactivity disorder

Intolerance of uncertainty (IU) has often been studied in the context of internalizing disorders, but no studies to our knowledge have explored the relation between IU and externalizing disorders. Given the proposed link between IU and emotion regulation, the current study sought to examine levels of IU in an externalizing clinical population with known emotion regulation difficulties—attention-deficit/hyperactivity disorder (ADHD). IU levels in this population were compared to a clinical population known to experience elevated levels of IU. Participants in present study were ninety-three children (36 anxiety disorder, 28 ADHD, 29 unaffected children) ages 7–13, who completed the Intolerance of Uncertainty Scale—Short Version (IUS). Responses on the IUS were converted to total IU, prospective IU, and inhibitory IU. A linear mixed model analysis of covariance was conducted while controlling for age, sex, and ADHD medications. A significant interaction was observed between diagnostic status and IU scale. Planned contrasts indicated that children with anxiety disorders and ADHD reported significantly higher levels of IU relative to unaffected children, and children with ADHD reported comparable levels of inhibitory IU relative to children with anxiety disorders. The current results contribute to a growing literature on the link between IU and psychopathology. IU appears to be a transdiagnostic construct present among children with internalizing and externalizing disorders, and may be broadly associated with emotion regulation deficits rather than specific disorder symptoms.     

Developmental comorbidity in attention-deficit/hyperactivity disorder

With the present review, we intend to highlight the importance of considering the age- and development-dependent occurrence of comorbidity in ADHD and to outline distinct trajectories of symptom progression with possible impact on course and outcome of ADHD. The review will focus on introducing the concepts of "developmental epidemiology" and "developmental comorbidity". Psychiatric and non-psychiatric age-dependent comorbidity can be seen in the majority of children, adolescents and adults with ADHD, resulting in a severe impairment of everyday life with considerable functional and psychosocial problems. Concerning the temporal order of occurrence, psychiatric conditions may be present before the appearance of first definite ADHD symptoms ("pre-comorbidity", such as temperament factors, sleep disturbance, autism spectrum disorders and atopic eczema). They may coincide with the time when ADHD symptoms reach a clinically significant level ("simultaneous comorbidity": enuresis, encopresis, developmental dyslexia). The majority of comorbidity, however, appears after the onset of ADHD in the course of disease ("post-comorbidity": tic disorder, depression and suicidality, anxiety disorders, obsessive compulsive disorder, bipolar disorder, conduct and substance use disorders, obesity and personality disorders). The aetio-pathophysiology of ADHD and its comorbid disorders and also the nature of comorbidity itself being highly heterogeneous, we additionally discuss possible models of comorbidity. In the future, longitudinal data on distinct patterns of symptom and comorbidity progression would help to refine disease classification systems, strengthen the power of future genetic studies and finally allow for more specific treatment strategies.     

A systematic review of circadian function,chronotype and chronotherapy in attention deficit hyperactivity disorder

Reports of sleep disturbances in attention deficit hyperactivity disorder (ADHD) are common in both children and adults; however, the aetiology of such disturbances is poorly understood. One potentially important mechanism which may be implicated in disrupted sleep in ADHD is the circadian clock, a known key regulator of the sleep/wake cycle. In this systematic review, we analyse the evidence for circadian rhythm changes associated with ADHD, as well as assessing evidence for therapeutic approaches involving the circadian clock in ADHD. We identify 62 relevant studies involving a total of 4462 ADHD patients. We find consistent evidence indicating that ADHD is associated with more eveningness/later chronotype and with phase delay of circadian phase markers such as dim light melatonin onset and delayed sleep onset. We find that there is evidence that melatonin treatment may be efficacious in addressing ADHD-related sleep problems, although there are few studies to date addressing other chronotherapeutic approaches in ADHD. There are only a small number of genetic association studies which report linkages between polymorphisms in circadian clock genes and ADHD symptoms. In conclusion, we find that there is consistent evidence for circadian rhythm disruption in ADHD and that such disruption may present a therapeutic target that future ADHD research might concentrate explicitly on.