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Themenschwerpunkt

ESCAlate – Ein adaptiver Behandlungsansatz für Jugendliche und Erwachsene mit ADHS

Published Online:September 24, 2018https://doi.org/10.1024/1661-4747/a000360

Abstract

Zusammenfassung. In der Behandlung der adulten ADHS haben sich sowohl pharmakologische Interventionen als auch psychosoziale Behandlungen als wirksam erwiesen. In der täglichen klinischen Routine wird die Behandlung jedoch weniger von den Ergebnissen klinischer Studien als von Behandlungsrichtlinien und Anforderungen nationaler Institutionen (Gemeinsamer Bundesausschuss) beeinflusst. Der Hauptaspekt dieser Vorschriften ist die Anforderung, dass ein stufenweiser Behandlungsansatz, beginnend mit niederschwelligen Interventionen, am sinnvollsten für die Behandlung bei adulten ADHS-Patienten ist. Leider gibt es bis heute fast ausschließlich klinische Studien, welche die Auswirkungen einzelner Therapiestrategien erforschen. Das gestufte Versorgungsmodell scheint noch nicht ausreichend validiert. Genau hier möchte die im Folgenden beschriebene ESCAlate-Studie ansetzen. Bei ESCAlate handelt es sich um eine randomisierte, kontrollierte Studie. Es sollen 279 Patienten im Alter zwischen 16.00 und 45.11 Jahren in das Behandlungsprogramm, welches sich in mehrere Abschnitte gliedert, aufgenommen werden. In einem ersten Behandlungsabschnitt werden die Patienten nach dem Zufallsverfahren in drei Gruppen eingeteilt: Psychoedukation im Einzelsetting (PE), Telefonassistierte Selbsthilfe (TASH) oder Wartekontrollgruppe. Alle Patienten der Wartegruppe erhalten nach dreimonatiger Wartezeit eine Behandlung mit TASH. Im zweiten Behandlungsabschnitt werden die Patienten entsprechend der Schwere ihrer persistierenden Symptome in die drei Gruppen Full-Responder, Partial-Responder und Non-Responder eingeteilt. Patienten, welche als Full-Responder eingestuft wurden erhalten ein verhaltenstherapeutisch orientiertes Coaching. Partial-Responder erhalten ebenfalls dieses Coaching, wobei in dieser Gruppe der Zufall entscheidet, ob die Patienten zusätzlich ein Neurofeedbacktraining (NF) erhalten. Non-Responder erhalten eine pharmakologische Behandlung mit Methylphenidat. Hier entscheidet ebenfalls der Zufall, ob die Patienten zusätzlich ein Neurofeedbacktraining erhalten. ESCAlate zeichnet sich durch eine relativ naturalistische Stichprobenzusammensetzung aus, da auf hochspezifische Ein- und Ausschlusskriterien verzichtet wurde, um eine Patientenstichprobe zu erhalten, die die Patienten der alltäglichen klinischen Routine in den Praxen widerspiegelt. Die Wirksamkeit einer evidenzbasierten Intervention mit gestufter Behandlung wird durch primäre (Verringerung des Schweregrads der ADHS-Symptome) und sekundäre Ergebnisse (funktionelle Ergebnisse; z.B. Lebensqualität, Ärger-Management, Steigerung des psychosozialen Wohlbefindens) untersucht. Prädiktoren für therapeutisches Ansprechen bzw. Nicht-Ansprechen werden bei jedem Schritt der Intervention evaluiert. Darüber hinaus können eventuelle geschlechtsspezifische Unterschiede untersucht werden.


ESCAlate – An adaptive treatment approach for adolescents and adults with ADHD

Abstract. In the treatment of adult ADHD, both pharmacological interventions and psychosocial treatments have been shown to be effective. However, in day-to-day clinical routine, treatment is less influenced by the outcomes of clinical trials than by treatment guidelines and requirements of national institutions (Federal Joint Committee). The main aspect of these regulations is the requirement that a step-by-step approach, starting with low-threshold interventions, is most appropriate for treatment in adult ADHD patients. Unfortunately, almost all clinical studies investigate the effects of individual therapeutic strategies. The tiered supply model does not seem to have been sufficiently validated yet. This is exactly where the ESCAlate study described below would like to start. ESCAlate is a randomized, controlled trial. 279 patients between the ages of 16.00 and 45,11 years will be enrolled in the treatment program, which is divided into several sections. In a first stage of treatment, patients are randomized into three groups: Individualized Psychoeducation (PE), Self-Helped Telephone Assisted Self-Help (TASH), or Waiting Control Group. All patients in the waiting group receive treatment with TASH after a waiting period of three months. In the second part of the treatment, patients are divided into the three groups full responders, partial responders and non-responders according to the severity of their persistent symptoms. Patients classified as full-responders receive behavioral-oriented coaching. Partial responders also receive this coaching, whereby in this group patients can be randomized to an additionally neurofeedback training (NF). Non-responders receive pharmacological treatment with methylphenidate and can be randomized to the additionally neurofeedbacktraining. ESCAlate is characterized by a relatively naturalistic sampling composition, as it does away with highly specific inclusion and exclusion criteria in order to obtain a patient sample that reflects the patients' daily routine in the practices. The effectiveness of an evidence-based intervention with graded treatment is assessed by primary (reduction in the severity of ADHD symptoms) and secondary outcomes (functional outcomes such as quality of life, anger management, increase in psychosocial well-being). Therapeutic response/non-response predictors are evaluated at each step of the intervention. In addition, any gender differences can be investigated.

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