托莫西汀联合认知行为疗法对注意缺陷多动障碍儿童的临床疗效分析

Clinical efficacy of atomoxetine combined with cognitive behavior therapy on children with attention deficit hyperactivity disorder

目的探讨托莫西汀联合认知行为疗法(cognitive-behavioral therapy, CBT)对注意缺陷多动障碍(attention deficit hyperactivity disorder, ADHD)儿童的临床疗效。方法选取104例门诊确诊的ADHD患儿, 根据随机数字表法分为托莫西汀组(n=34)、CBT组(n=35)和托莫西汀联合CBT组(n=35), 在治疗12周前后采用儿童困难问卷(questionnaire-children with difficulties, QCD)、Swanson儿童行为量表(Swanson child behavior checklist, SNAP-Ⅳ)和Conners父母问卷(Conners parents rating scales, CPRS)评估疗效, 并监测治疗过程中的不良反应。采用SPSS 23.0统计软件进行统计分析。同组治疗前后评分比较使用配对样本t检验, 三组间治疗后与治疗前评分差值比较使用单因素方差分析。结果 (1)托莫西汀联合CBT治疗后与治疗前相比QCD量表评分升高[(32.96±3.01)分, (43.00±2.22)分](t=-13.35, P<0.01), SNAP-Ⅳ量表的注意缺陷[(15.67±3.46)分, (6.07±1.73)分]、多动/冲动[(13.59±3.41)分, (7.30±2.43)分]、对立违抗维度[(9.85±3.98)分, (2.59±2.17)分]及总分[(39.11±6.65)分, (16.59±3.91)分]评分均降低(t=14.96, 10.87, 11.77, 21.49,均P<0.01), CPRS量表的品行问题[(0.81±0.30)分, (0.70±0.26)分]、学习问题[(1.58±0.31)分, (0.32±0.13)分]、心身障碍[(0.22±0.25)分, (0.16±0.20)分]、冲动-多动[(1.27±0.37)分, (0.71±0.18)分]、焦虑[(0.32±0.26)分, (0.23±0.17)分]、多动指数[(1.19±0.40)分, (0.79±0.22)分]六因子评分均降低(t=2.71, 21.23, 2.41, 8.87, 2.96, 6.19, 均P<0.05)。(2)三组患儿在QCD评分、SNAP-Ⅳ量表中的注意缺陷维度、CPRS量表中的学习问题、冲动-多动维度差值的组间差异均具有统计学意义(均P<0.05)。(3)LSD事后比较显示, 在QCD评分中, CBT组的治疗前后差值变化显著低于托莫西汀组和托莫西汀联合CBT组(均P<0.05);在SNAP-Ⅳ的注意缺陷维度上, CBT组的治疗前后差值显著低于托莫西汀联合CBT组(P<0.01);在CPRS的学习问题和冲动-多动维度上, 托莫西汀联合CBT组变化均显著高于托莫西汀组和CBT组(均P<0.01)。三组治疗过程中均未发生严重不良反应。结论托莫西汀联合CBT治疗相较于单纯托莫西汀或CBT治疗有更好的疗效, 能有效改善ADHD儿童的核心症状, 提高日常生活功能, 并有较高安全性。

Objective To investigate the clinical efficacy of atomoxetine combined with cognitive-behavioral therapy(CBT)on children with attention deficit hyperactivity disorder(ADHD).Methods Totally 104 children diagnosed with ADHD were randomly divided into atomoxetine group(n=34),CBT group(n=35)and atomoxetine combined with CBT group(n=35).After 12 weeks of treatment,questionnaire-children with difficulties(QCD),Swanson child behavior checklist(SNAP-Ⅳ)and Conners parents rating scales(CPRS)were used to evaluate the efficacy and recorded the adverse reactions during the treatment.SPSS 23.0 software was used for statistical analysis.Paired sample t-test was used to compare the scores of the same group before and after treatment,and one-way ANOVA was used to compare the difference between the three groups after treatment.Results(1)Compared with baseline,the score of QCD increased(32.96±3.01,43.00±2.22)(t=-13.35,P<0.01),while the attention deficit(15.67±3.46,6.07±1.73),hyperactivity/impulse(13.59±3.41,7.30±2.43),opposition disobedience(9.85±3.98,2.59±2.17)and total score(39.11±6.65,16.59±3.91)of SNAP-Ⅳdecreased in atomoxetine combined with CBT group after treatment(t=14.96,10.87,11.77,21.49,all P<0.01).The factor scores of behavior problems(0.81±0.30,0.70±0.26),learning problems(1.58±0.31,0.32±0.13),psychosomatic disorders(0.22±0.25,0.16±0.20),impulse hyperactivity(1.27±0.37,0.71±0.18),anxiety(0.32±0.26,0.23±0.17)and hyperactivity index(1.19±0.40,0.79±0.22)of CPRS also decreased(t=2.71,21.23,2.41,8.87,2.96,6.19,all P<0.05)in atomoxetine combined with CBT group after treatment.(2)After treatment,the changes of QCD scores,attention deficit dimension in SNAP-Ⅳscale,learning problems and impulse hyperactivity dimension in CPRS scale of the three groups before and after treatment were statistically significant(all P<0.05).(3)Post LSD comparison showed that the change in CBT group was significantly lower than that in atomoxetine group and atomoxetine combined CBT group in QCD score(both P<0.05).In the dimension of attention deficit of SNAP-Ⅳ,the difference in CBT group was significantly lower than that in atomoxetine combined CBT group(P<0.01).In the learning problems and impulse hyperactivity dimensions of CPRS,the changes of atomoxetine combined with CBT group were significantly higher than those of atomoxetine group and CBT group(all P<0.01).Conclusion Atomoxetine combined with CBT has better curative effect than atomoxetine or CBT alone in patients with ADHD.It can effectively improve the core symptoms and daily life function of ADHD children,and has high safety.