Prioriteringsriktlinjer för Autism

Transkript

1 Prioriteringsriktlinjer för Autism Tillstånd DSM-IV ICD-10 Angelägenhetsgrad GAF Medicinskt acceptabel väntetid Åtgärd Effekt av åtgärd Grad av vetenskaplig dokumentation Risk med åtgärd Qualy Nytta av åtgärd Vårdnivå Vårdform Autism/autismliknande tillstånd /F /F /F Inom 1 månad TEACCH 1 C/D Viss Liten 1-2 L ÖV ABA/TBA 2 C/D Viss/god Liten 1-2 L ÖV Föräldrautbildning 3 D Viss Liten 1 L ÖV Metylfenidat 4 D Viss Liten 1-2 L ÖV Atomoxetin 5 D Viss Liten 1-2 L ÖV Melatonin 6 D Viss Liten 1-2 L ÖV Risperidon 7 D Viss/god Liten/ måttlig 2-3 L ÖV Högfungerande autism/aspergers syndrom /F Inom 3 månader Föräldrautbildning 3 D Viss Liten 1 L ÖV Metylfenidat 4 D Viss Liten 1-2 L ÖV Atomoxetin 5 D Viss Liten 1-2 L ÖV Melatonin 6 D Viss Liten 1-2 L ÖV KBT 8 D Viss Liten 1-2 L ÖV SSRI 9 D Ringa Liten/ måttlig 2-3 L ÖV 1

2 Angelägenhetsgrad Patienten befinner sig i ett tillstånd som om vårdinsats inte görs medför: 1. Omedelbart livshot 2. Risk för mycket allvarlig skada, för tidig död, betydande invaliditet och outhärdlig situation 3. Risk för allvarlig skada, bestående men eller mycket låg livskvalitet 4. Risk för förväntad försämring/ej vidmakthållen funktion-adl-nivå 5. Risk för betydande olägenhet, ökad sjuklighet, förlängd sjukdomsperiod, sänkt livskvalitet 6. Risk för olägenhet, skada, bestående men eller låg livskvalitet 7. Sannolikt ökad risk för försämrad hälsoupplevelse eller icke optimal livskvalitet 8. Möjligen ökad risk för sjuklighet, försämring av funktionsnivå eller livskvalitet 9. Risk för sänkt livskvalitet enligt patientens uppfattning och vetenskap och beprövad kunskap inte motsäger detta 10. Ingen risk för ökad sjuklighet, försämrad funktionsnivå eller försämrad livskvalitet Global Assessment of Function (GAF) För uppskattning/bedömning av patientens vårdbehov (länk till pdf fil). Medicinskt acceptabel väntetid Inom 1 vecka GAF 1-30 inom 3 månader GAF Åtgärder Allmänna behandlingsriktlinjer Autism är liktydigt med en kognitiv funktionsnedsättning som förekommer i olika varianter och svårighetsgrader. Vårdplanen skall baseras på en individuellt anpassad medicinsk, neuropsykologisk, pedagogisk och social utredning. Förekomsten av andra funktionsnedsättningar måste särskilt beaktas. Ett antal vetenskapliga studier talar för att tidiga insatser är av betydelse för barn med autism. Program för tidiga, mångsidiga och intensiva insatser har utvecklats i syfte att positivt kunna påverka barnets utveckling. Ändamålsenlig och effektiv habilitering reducerar de autistiska symtomen och stödjer utvecklingen av grundläggande sociala, kommunikativa och kognitiva färdigheter. Habiliteringsplanen skall utmärkas av: inlärningsstrategier baserade på tillämpad beteendeanalys (TBA) med utgångspunkt från barnets specifika funktionsnedsättningar, föräldramedverkan, kontinuerlig och långsiktig planering, åtgärder som bygger på befintlig forskning och att insatserna består av mångsidiga strategier och förhållningssätt som tillämpas i olika miljöer av utbildad personal. Konsensus råder kring betydelsen av att strukturera, organisera och visualisera omgivningen för att öka barnets förståelse, reducera stress och underlätta inlärning. Följande faktorer är relaterade till behandlingseffekt: tidigt insatta insatser, hög intensitet, individualiserade, välplanerade och systematiskt upplagda inlärningstillfällen i anpassade miljöer, fokus på prioriterade områden som barn med autism har svårigheter med, möjlighet att vara tillsammans med normalutvecklade jämnåriga, föräldramedverkan, utbildad personal, hög personaltäthet och planering för övergång mellan förskola och skola. Mångsidiga intensiva insatser för barn med autism i förskoleåldern, en rapport inom projektet evidensbaserad habilitering (Bohlin och medarb. 2004, utgiven av Föreningen Sveriges habiliteringschefer i samarbete med Handikapp & Habilitering, Stockholms läns landsting) ger en översikt av habiliteringsstudier. 2

3 Läkemedelsbehandling är befogat vid associerade beteendeproblem som t.ex. svår aggressivitet och självdestruktivitet, överaktivitet och koncentrationssvårigheter och symtom som sömnrubbningar och depressivitet. Insatser i barnets miljö I skolan, på fritidshem och i övriga miljöer där barnet vistas regelbundet är det viktigt att skapa en autismvänlig miljö som minimerar för barnet störande faktorer och möjliggör tydlig kommunikation i syfte att förebygga och minska dysfunktionella beteenden. Sådana faktorer utgörs t.ex. av att barnet erbjuds visuellt stöd och förbereds på kommande aktiviteter, anpassad miljö, anpassade aktiviteter, tillgång till normalutvecklade jämnåriga. Beskrivning av specifika metoder 1) Treatment and Education of Autistic and related Communication Handicapped Children (TEACCH) TEACCH är en undervisningsmetod/pedagogiskt arbetssätt och ett förhållningssätt anpassat för i första hand individer med lågfungerande autism och autismliknande tillstånd. Programmet syftar till att träna ADL-funktioner för att göra personerna mer självständiga. Man använder sig av visuellt stöd i form av schema och arbetsordningar med tydlig struktur för att träna funktionella beteenden. I programmet ingår också psykopedagogiskt föräldrastöd. Ozonoff, S. & Cathcart, K. (1998). Effectiveness of a home program intervention for young children with autism. J Autism Dev Disorder, 28, This project evaluated the effectiveness of a TEACCH-based home program intervention for young children with autism. Parents were taught how to work with their preschool autistic child in the home setting, focusing on cognitive, academic, and prevocational skills essential to later school success. To evaluate the efficacy of the program, two matched groups of children were compared, a treatment group and a no-treatment control group, each consisting of 11 subjects. The treatment group was provided with approximately 4 months of home programming and was tested before and after the intervention with the Psychoeducational Profile-Revised (PEP-R). The control group did not receive the treatment but was tested at the same 4-month interval. The groups were matched on age, pretest PEP-R scores, severity of autism, and time to follow-up. Results demonstrated that children in the treatment group improved significantly more than those in the control group on the PEP-R subtests of imitation, fine motor, gross motor, and nonverbal conceptual skills, as well as in overall PEP-R scores. Progress in the treatment group was three to four times greater than that in the control group on all outcome tests. This suggests that the home program intervention was effective in enhancing development in young children with autism. 2) Applied Behaviour Analysis/Tillämpad BeteendeAnalys (ABA/TBA) Olika typer av beteendeterapeutiska tekniker kommer till användning. Som positiv förstärkning används tydligt beröm eller något annat som barnet uppskattar. Vid oönskat beteende används ett bestämt nej eller negligering. Eikeseth, S., Smith, T., Jahr, E. & Eldevik, S. (2007). Outcome for children with autism who began intensive behavioral treatment between ages 4 and 7: a comparison controlled study. Behav Modif, 3: This study extends findings on the effects of intensive applied behavior analytic treatment for children with autism who began treatment at a mean age of 5.5 years. The behavioral treatment group (n = 13, 8 boys) was compared to an eclectic treatment group (n = 12, 11 boys). Assignment to groups was made independently based on the availability of qualified supervisors. Both behavioral and eclectic treatment took place in public kindergartens and elementary schools for typically developing children. At a mean age of 8 years, 2 months, the behavioral treatment group showed larger increases in IQ and adaptive functioning than did the eclectic group. The behavioral treatment group also displayed fewer aberrant behaviors and social problems at follow-up. Results suggest that behavioral treatment was effective for children with autism in the study. 3

4 Magiati, I., Charman, T. & Howlin, P. (2007). A two-year prospective follow-up study of community-based early intensive behavioural intervention and specialist nursery provision for children with autism spectrum disorders. Journal of Child Psychology and Psychiatry, 48, BACKGROUND: This prospective study compared outcome for pre-school children with autism spectrum disorders (ASD) receiving autism-specific nursery provision or homebased Early Intensive Behavioural Interventions (EIBI) in a community setting. METHODS: Forty-four 23- to 53-month-old children with ASD participated (28 in EIBI homebased programmes; 16 in autism-specific nurseries). Cognitive, language, play, adaptive behaviour skills and severity of autism were assessed at intake and 2 years later. RESULTS: Both groups showed improvements in age equivalent scores but standard scores changed little over time. At follow-up, there were no significant group differences in cognitive ability, language, play or severity of autism. The only difference approaching significance (p =.06), in favour of the EIBI group, was for Vineland Daily Living Skills standard scores. However, there were large individual differences in progress, with intake IQ and language level best predicting overall progress. CONCLUSIONS: Homebased EIBI, as implemented in the community, and autism-specific nursery provision produced comparable outcomes after two years of intervention. Lövåsmetoden (Lovaas) bygger på ABA/TBA och innebär en högintensiv beteendeterapi för personer med autism. Metoden är utarbetad av Ivar Lovaas, norsk professor i psykologi, utbildad och bosatt i USA. Lovaas, O. I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3-9. Autism is a serious psychological disorder with onset in early childhood. Autistic children show minimal emotional attachment, absent or abnormal speech, retarded IQ, ritualistic behaviors, aggression, and self-injury. The prognosis is very poor, and medical therapies have not proven effective. This article reports the results of behavior modification treatment for two groups of similarly constituted, young autistic children. Follow-up data from an intensive, long-term experimental treatment group (n = 19) showed that 47% achieved normal intellectual and educational functioning, with normal-range IQ scores and successful first grade performance in public schools. Another 40% were mildly retarded and assigned to special classes for the language delayed, and only 10% were profoundly retarded and assigned to classes for the autistic/retarded. In contrast, only 2% of the control-group children (n = 40) achieved normal educational and intellectual functioning; 45% were mildly retarded and placed in language-delayed classes, and 53% were severely retarded and placed in autistic/retarded classes. Även om många replikerat Lovaas resultat har de också kritiserats. Schopler, E., Short, A., Mesibov, G. (1989). Relation of behavioral treatment to "normal functioning": comment on Lovaas. J Consult Clin Psychol., 57, Our commentary is a critique of the Lovaas (1987) study on the outcome of intensive behavioral intervention with young autistic children. Problems in the following aspects of the study are reviewed: (a) the choice of outcome measures, (b) the criteria for subject selection and the intellectual level of the subjects, and (c) the method for assigning subjects to control groups. Based on the available data, we posit that it is not possible to determine the effects of the intervention. 3) Föräldrautbildning Målet med föräldrautbildning är att öka föräldrars kunskap om autism och hjälpa dem att bli delaktiga i barnets behandling. Alla mångsidiga vårdprogram för barn med autism innehåller föräldramedverkan som en viktig komponent. Flera studier visar att föräldrastress minskar när föräldrar lär sig strategier för att påverka barnets beteende. Både TBAoch TEACCH-programmen betonar föräldramedverkan. I föräldrautbildning ingår information om stödinsatser och rättigheter. Föräldrar ges möjlighet att delta i stöd-/ samtalsgrupper tillsammans med andra föräldrar och erbjuds samordning av insatser som kan tillgodose inte bara föräldrars utan även syskons behov av stöd. 4

5 Jocelyn, L. J., Casiro, O. G., Beattie, D., Bow, J. & Kneisz, J. (1998). Treatment of children with autism: a randomized controlled trial to evaluate a caregiver-based intervention program in community day-care centers. J Dev Behav Pediatr., 19, This study reports on the results of a randomized controlled trial that evaluated a caregiver-based intervention program for children with autism in community day-care centers. Thirty-five preschool children with a DSM III-R diagnosis of autism or pervasive developmental disorder were randomized to an experimental or control group. Children in the experimental group were enrolled in day care and their parents and child care workers received a 12-week intervention consisting of lectures and on-site consultations to daycare centers. In addition, supportive work was undertaken with families. Control subjects received day care alone. In the experimental group, there were greater gains in language abilities, significant increases in caregivers' knowledge about autism, greater perception of control on the part of mothers, and greater parent satisfaction. We conclude that this research design demonstrated that the intervention was significantly superior to day care alone. Diggle, T., McConachie, H. R. & Randle, V. R. (2003). Parent-mediated early intervention for young children with autism spectrum disorder. Cochrane Database Syst Rev., CD BACKGROUND: Recent estimates concerning the prevalence of autistic spectrum disorder are much higher than those reported 30 years ago, with at least 1 in 400 children affected. This group of children and families have important service needs. The involvement of parents in implementing intervention strategies designed to help their autistic children has long been accepted as helpful. The potential benefits are increased skills and reduced stress for parents as well as children. OBJECTIVES: The objective of this review was to determine the extent to which parent-mediated early intervention has been shown to be effective in the treatment of children aged 1 year to 6 years 11 months with autistic spectrum disorder. In particular, it aimed to assess the effectiveness of such interventions in terms of the benefits for both children and their parents. SEARCH STRATEGY: A range of psychological, educational and biomedical databases were searched. Bibliographies and reference lists of key articles were searched, field experts were contacted and key journals were hand searched. SELECTION CRITERIA: Only randomised or quasi-randomised studies were included. Study interventions had a significant focus on parent-implemented early intervention, compared to a group of children who received no treatment, a waiting list group or a different form of intervention. There was at least one objective, child related outcome measure. DATA COLLECTION AND ANALYSIS: Appraisal of the methodological quality of included studies was carried out independently by two reviewers. Differences between the included studies in terms of the type of intervention, the comparison groups used and the outcome measures were too great to allow for direct comparison. MAIN RESULTS: The results of this review are based on data from two studies. Two significant results were found to favour parent training in one study: child language and maternal knowledge of autism. In the other, intensive intervention (involving parents, but primarily delivered by professionals) was associated with better child outcomes on direct measurement than were found for parent-mediated early intervention, but no differences were found in relation to measures of parent and teacher perceptions of skills and behaviours. REVIEWER'S CONCLUSIONS: This review has little to offer in the way of implications for practice: there were only two studies, the numbers of participants included were small, and the two studies could not be compared directly to one another. In terms of research, randomised controlled trials involving large samples need to be carried out, involving both short and long-term outcome information and full economic evaluations. Research in this area is hampered by barriers to randomisation, such as availability of equivalent services. 4) Metylfenidat Indikation för metylfenidat och övrig centralstimulantia är överaktivitet/impulsivitet/uppmärksamhetsstörning. Santosh, P. J., et al. (2006). Impact of comorbid autism spectrum disorders on stimulant response in children with attention deficit hyperactivity disorder: a retrospective and prospective effectiveness study. Child Care Health Dev, 32, BACKGROUND: In the recent past, psychiatrists and paediatricians have avoided prescribing stimulant medication, such as methylphenidate and dexamphetamine to patients with autism spectrum disorders (ASD) because of both doubts about efficacy and concern that these medications make stereotypies worse. Recently, a number of small trials have suggested that methylphenidate does have a role in the management of hyperactivity in children with autistic spectrum disorders. METHODS: Children with ASD and 5

6 attention deficit hyperactivity disorder (ADHD), and children with ADHD without ASD received standard treatment with methylphenidate from one specialist centre. A combination of standardized and novel outcome tools was used to allow both an exploratory retrospective study of 174 children and then a prospective study of a further 52 children to be carried out. RESULTS: After treatment with stimulants, the subjects in both groups showed statistically significant improvements in target symptoms of 'hyperactivity', 'impulsivity', 'inattention', 'oppositionality', 'aggression' and 'intermittent explosive rage'. The Clinical Global Impression-Improvement and efficacy index measures also improved in each group. In both the retrospective and the prospective studies, there was no statistically significant difference in the degree of improvements between each group. Importantly, neither tics nor repetitive behaviours worsened in either group. Children in the 'ADHD-only' group who were prescribed stimulants experienced significant 'nausea', 'giddiness', 'headaches' and 'sleep difficulties', whereas sleep difficulties were the only side effect that emerged in children in the ASD with ADHD group. CONCLUSIONS: Both studies presented here support previous findings from smaller studies that show children with autism and ADHD can respond as well to stimulants as children with ADHD alone. Although randomized controlled trials remain the gold standard for efficacy studies, systems like this that allow clinicians to continue rigorous and consistent monitoring for many years have a valuable role to play. Furthermore, such monitoring systems which now exist electronically can easily accumulate large data sets and reveal details about long-term effectiveness and long-term side effects of medication that are unlikely to be discovered in short-term trials. 5) Atomoxetin Indikation för atomoxetin är överaktivitet/impulsivitet/uppmärksamhetsstörning. Arnold, L. E., Aman, M. G., Cook, A. M., et al. (2006). Atomoxetine for hyperactivity in autism spectrum disorders: placebo-controlled crossover pilot trial. J Am Acad Child Adolesc Psychiatry, 45, OBJECTIVE: To explore placebo-controlled efficacy and safety of atomoxetine (ATX) for attention-deficit/hyperactivity disorder (ADHD) symptoms in children with autism spectrum disorders (ASD). METHOD: Children ages 5 to 15 with ASD and prominent ADHD symptoms were randomly assigned to order in a crossover of clinically titrated ATX and placebo, 6 weeks each, separated by 1-week washout. Slopes for each condition were compared by paired t test. RESULTS: In , 12 boys and 4 girls (7 with autistic disorder, 1 Asperger's, 8 pervasive developmental disorder not otherwise specified) all completed at least 3 weeks of each condition. On the primary outcome, the Hyperactivity subscale of the Aberrant Behavior Checklist, ATX was superior to placebo (p =.043, effect size d = 0.90). It was also superior on a 0 to 3 rating of nine DSM-IV ADHD hyperactive/impulsive symptoms (p =.005, d = 1.27), but missed significance on nine inattentive symptoms (p =.053, d= 0.89). Nine subjects responded to ATX, four to placebo (25% improvement on the Hyperactivity subscale plus Clinical Global Impressions-Improvement of 1-2. One was rehospitalized for recurrent violence on ATX. Adverse events were otherwise tolerable, with no tendency to stereotypy. CONCLUSIONS: ATX appears safe and effective for treating hyperactivity in some children with autism spectrum disorders. The effect appears as large as in a multisite methylphenidate trial in the same population, with fewer intolerable side effects. Further study in autism spectrum disorders is indicated. 6) Melatonin Indikation för Melatonin är insomningssvårigheter och dygnsrytmstörningar. Garstang, J. & Wallis, M. (2006). Randomized controlled trial of melatonin for children with autistic spectrum disorders and sleep problems. Child Care Health Dev., 32, BACKGROUND: Melatonin is often used for autistic children with sleep disorders, despite a lack of published evidence in this population. METHODS: A randomized, placebocontrolled double-blind crossover trial of melatonin was undertaken in 11 children with autistic spectrum disorder (ASD). RESULTS: Seven children completed the trial. Sleep latency was 2.6 h [95% confidence intervals (CI) ] baseline, 1.91 h (95% CI ) with placebo and 1.06 h (95% CI ) with melatonin. Wakings per night were 0.35 (95% CI ) baseline, 0.26 (95% CI ) with placebo and 0.08 (95% CI ) with melatonin. Total sleep duration was 8.05 h (95% CI ) baseline, 8.75 h (95% CI ) with placebo and 9.84 h (95% CI ) with melatonin. CONCLUSIONS: Although the study was small owing to recruitment difficulties, it still provides evidence of effectiveness of melatonin in children with sleep difficulties and ASD, which we predict a larger study would confirm. 6

7 Paavonen, E. J., Nieminen-von Wendt, T., Vanhalam R., Aronenm E. T.& von Wendt, L. (2003). Effectiveness of melatonin in the treatment of sleep disturbances in children with Asperger disorder. J Child Adolesc Psychopharmacol, 13, Sleep disturbances are common in patients with Asperger disorder. Although these sleep problems are often persistent and may significantly impair the child's daytime wellbeing, no treatment studies have been reported. In this open clinical trial, the effectiveness of melatonin was studied in a sample of 15 children with Asperger disorder (13 boys, 2 girls) aged 6-17 years using several questionnaires and actigraph measurements. They included assessments of sleep quality, tiredness, and behavior. Melatonin (3 mg/day) was used for 14 days. All the measurements were made three times: before the treatment period, during the treatment (days 12-14), and 3 weeks after the discontinuation of the treatment. The sleep patterns of all the children improved, and half of them displayed excellent responses to melatonin. In particular, actigraphically measured sleep latency decreased from / minutes to / minutes (p = 0.002), whereas sleep duration remained steady at / minutes and / minutes. Despite the short duration of the treatment, behavioral measures also displayed a significant improvement, and most of the effect disappeared after the discontinuation of the melatonin (p = 0.001). In conclusion, melatonin may provide an interesting new and well-tolerated treatment option for children with Asperger disorder suffering from chronic insomnia. However, these results must be confirmed in a controlled study. 7) Risperidon Indikation för Risperidon är svårt aggressivt och självdestruktivt beteende Jesner, O. S., Aref-Adib, M., & Coren, E. (2007). Risperidone for autism spectrum disorder. Cochrane Database Syst Rev., 24, CD BACKGROUND: Autistic spectrum disorder encompasses a wide variety of behavioural and communicative problems. Both the core features and non-core features of autism have been targeted in a variety of therapies. Atypical antipsychotic medications, including risperidone, have been used for symptom and behaviour improvement and have shown beneficial outcomes, particularly in certain aspects of the disorder. However, given the nature of the condition presenting in young patients, the risks of these potentially long term therapies must be weighed against the benefits. OBJECTIVES: To determine the efficacy and safety of risperidone for people with autism spectrum disorder. SEARCH STRATEGY: Electronic databases: CENTRAL (Cochrane Central Register of Controlled Trials) 2006 (Issue 3); MEDLINE (1966 to April 2006); EMBASE (1980 to April 2006); PsycINFO (1887 to April 2006); CINAHL (1982 to April 2006); LILACS (1982 to April 2006 ); Clinicaltrials.gov (USA) (accessed April 2006); ZETOC (1993 to April 2006); National Research Register (NRR) (UK) 2006 (Issue 1) were searched. In addition further data were retrieved through contact with pharmaceutical companies and authors of published trials. SELECTION CRITERIA: All randomised controlled trials of risperidone versus placebo for patients with a diagnosis of autism spectrum disorder. All trials had to have at least one standardised outcome measure used for both intervention and control group. DATA COLLECTION AND ANALYSIS: Data were independently evaluated and analysed by the reviewers. Data were evaluated at the end of each randomised controlled trial. Unpublished data were also considered and analysed. MAIN RESULTS: Only three randomised controlled trials were identified. Meta-analysis was possible for three outcomes. Some evidence of the benefits of risperidone in irritability, repetition and social withdrawal were apparent. These must however be considered against the adverse effects, the most prominent being weight gain. AUTHORS' CONCLUSIONS: Risperidone can be beneficial in some features of autism. However there are limited data available from studies with small sample sizes. In addition, there lacks a single standardised outcome measure allowing adequate comparison of studies, and long-term follow up is also lacking. Further research is necessary to determine the efficacy pf risperidone in clinical practice. 8) Kognitiv-Beteendeterapi (KBT) KBT kan övervägas vid behandling av ilska hos personer med Aspergers syndrom Sofronoff, K., Attwood, T., Hintonm S. & Levin, I. (2007). A randomized controlled trial of a cognitive behavioural intervention for anger management in children diagnosed with Asperger syndrome. J Autism Dev Disord, 37,

8 The purpose of the study described was to evaluate the effectiveness of a cognitive behavioural intervention for anger management with children diagnosed with Asperger syndrome. Forty-five children and their parents were randomly assigned to either intervention or wait-list control conditions. Children in the intervention participated in six 2-h weekly sessions while parents participated in a larger parent group. Parent reports indicated a significant decrease in episodes of anger following intervention and a significant increase in their own confidence in managing anger in their child. Qualitative information gathered from parents and teachers indicated some generalization of strategies learned in the clinic setting to both home and school settings. Limitations of the study and suggestions for future research are also discussed. 9) SSRI SSRI kan övervägas vid depressivitet och ångest hos personer med Aspergers syndrom och högfungerande autism enligt vedertagna indikationer för behandling med dessa läkemedel. Vid bedömning av depressivitet är det viktigt att differentiera mellan individens autistiska beteendemönster och depressiva symtom. Det finns mycket få SSRIstudier på individer i dessa patientgrupper. Abstract Martin, A., Koenig, K., Anderson, G. M. & Scahill, L. (2003). Low-dose fluvoxamine treatment of children and adolescents with pervasive developmental disorders. A prospective, open-label study. J Autism Dev Disord, 33, The objective of this study was to assess the efficacy and tolerability of low-dose fluvoxamine (1.5 mg/kg/day) in youngsters with pervasive developmental disorders (PDDs). This was a prospective, open-label trial that included 18 subjects with a mean age of /- 3.6 years. Fourteen children (78%) completed the 10-week study. Premature discontinuation due to behavioral activation occurred in three participants. Although there was no response for the group as a whole, eight subjects (including all four females) were considered at least partial responders in intent-to-treat analyses. Neither pubertal status nor serotonin levels predicted clinical response. Fluvoxamine can be beneficial in the treatment of select children and adolescents with PDDs. Gender differences in selective serotonin reuptake inhibitor (SSRI) response warrant further investigation. Effekt av åtgärd A. Sjuklighet - död kan förhindras B. Tillståndet kan botas C. Sjuklighet påverkas mycket, överlevnaden förlängs D. Sjukligheten påverkas i viss utsträckning E. Ingen effekt, F. Risk för försämring Grad av vetenskaplig dokumentation: God: Viss: Ringa: Ingen: Två eller flera oberoende relevanta RCT med statistisk signifikanta och entydiga resultat eller meta analyser med entydiga resultat. Flera kontrollerade studier eller enstaka mindre RCT med entydiga resultat eller större RCT med divergerande resultat. Fallserier vid olika centra och/eller enstaka kontrollerade studier eller enstaka RCT med motsägelsefulla resultat. Enstaka fallbeskrivningar. Risk med åtgärd Stor Risk Måttlig risk Liten risk 8

9 Om möjligt anges andelen riskpatienter, exempelvis < 5 % Qaly Kostnad per kvalitetsjusterade levnadsår alternativt vunnet levnadsår. Låg < kr/qaly alternativt vunnet levnadsår Måttlig kr/qaly alternativt vunnet levnadsår Hög miljon kr/ QALY alternativt vunnet levnadsår Mycket hög > 1 miljon kr/qaly alternativt vunnet levnadsår Ej bedömningsbar Nytta av åtgärd Sammanvägning av beprövad erfarenhet, effekt av åtgärd, grad av vetenskaplig dokumentation, risk med åtgärd och kostnadseffektivitet Bedöm graden av nytta från 1-4 där 1 är stor och 4 är liten. Vårdnivå L = Länssjukvård R = Regional vård H = Högspecialiserad vård Vårdform SV = Slutenvård ÖV = Öppenvård 9