1

danarTi 1

yuradRebis deficitisa da

hiperaqtivobis sindromis

marTva saskolo asakis

bavSvebsa da mozrdilebSi

pirveladi jandacvis doneze

klinikuri praqtikis erovnuli rekomendacia

(gaidlaini)

damtkicebulia saqarTvelos Sromis, janmrTelobisa da socialuri dacvis

ministris 2010 wlis 11 oqtombris # 332/o brZanebiT

miRebulia “klinikuri praqtikis erovnuli rekomendaciebis (gaidlainebi) da daavadebaTa marTvis saxelmwifo

standartebis (protokolebi) SemuSavebis, Sefasebisa da danergvis erovnuli sabWos"

2009 wlis 30 dekembris #2 sxdomis gadawyvetilebis Sesabamisad

2

yuradRebis deficitisa da hiperaqtivobis

sindromis marTva saskolo asakis bavSvebsa da

mozrdilebSi pirveladi jandacvis doneze

1. ganmarteba, sinonimebi, klasifikacia da

terminologia

ganmarteba:

ADHD warmoadgens heterogenul qceviT sindroms, mimdinares yuradRebis koncentrirebis deficitiT, hiperaqtivobiTa da impulsurobiT.

yuradRebis deficiti, hiperaqtivobis sindromi (ADHD) warmoadgens neiro-bihevialuri 1 ganviTarebis aSlilobas 2 . ADHD identificirebulia, rogorc `uyuradRebobis da hiperaqtivoba-impulsurobis mdgradi magaliTi, romelic ufro xSirad mJRavndeba da ufro mZimea, vidre Cveulebriv SeiniSneba individebSi, romlebic imyofebian ganviTarebis analogiur doneze~3.

yuradRebis deficitis/hiperaqtivobis sindromi da hirperkinetikuri aSlilobis ganmarteba (ICD-10) efuZneba impulsurobis, hiperaqtivobis da yuradRebis koncentrirebis deficitis Zalian maRali doniT gamovlinebas. am simptomebis konstatacia SesaZlebelia bavSvis qcevaze dakvirvebiT: naadrevi da gauazrebel moqmedebebi impulsurobaze miuTiTebs, mousvenari da xSirad cvalebadi moZraoba hiperaqtivobaze, xolo moqmedebebis araorganizebuloba, xangrZlivi da guldasmiTi Zalisxmevis uunaroba - yuradRebis koncentrirebis deficitze.

ADHD ganixileba, rogorc bavSvobis asakisaTvis damaxasiaTebeli diagnozi, Tumca simptomebi SeiZleba mozrdil asakSic gagrZeldes4. arsebuli SefasebebiT amerikel mozrdilTa 4,7 procents aReniSneba ADHD5 . ADHD-s diagnozi ori - oTxjer ufro xSirad ismeba biWebSi, vidre gogonebSi6,7 , Tumca rigi mkvlevarebis azriT, es gansxvaveba SesaZlebelia aixsnas maswavleblebis subieqturi damokidebulebiT (mikerZoebiT)8.

klasifikacia

ADHD warmoadgens ganviTarebis darRvevas, romelis drosac garkveuli damaxasiaTebeli niSnebi, rogoricaa hiperaqtiuroba, yuradRebis deficiti iwvevs CamorCenas ganviTarebaSi9. Tavis tvinis Subliswina qerqis magnituri rezonansis gamosaxulebiT ganviTarebis es Seferxeba ZiriTadad vlindeba 3-dan 5 wlis

3

asakSi 10 . varaudoben, rom swored es Seferxebebi iwvevs janmrTelobis gauaresebas 11 . ADHD aseve klasificirebulia rogorc qcevis aSliloba. Tumca, ADHD-is diagnozi, ar gulisxmobs nevrologiur daavadebas.

ADHD klasificirebulia rogorc qcevis dezorganizaciuli aSliloba, qcevis aSlilobasa da antisocialur aSlilobasTan erTad12.

ADHD-s sami qvetipi gaaCnia:

1. upiratesad hiperaqtiur-impulsuri;

2. upiratesad yuradRebis deficitiT mimdinare;

3. kombinirebuli - hiperaqtiur-impulsuri da uyuradReboba.

bavSvTa asakSi arsebuli ADHD

yuradRebis deficiti, hiperaqtivobis sindromi (ADHD) warmoadgens gavrcelebul bavSvTa daavadebas, romlis mkurnaloba SesaZlebelia. ADHD-s SeuZlia tvinis im garkveuli ubnebis dazianeba, romlebic gvaZleven problemebis gadawyvetis, winaswari dagegmvis, sxvaTa qmedebis gagebis da zraxvebis kontrolis saSualebas13.

mozrdilTa ADHD.

dadgenilia, rom aSS-Si daaxloebiT 8 milion mozrdils aqvs ADHD 14 . ADHD-s mqone ganukurnebel mozrdilebs xSirad aqvT cxovrebis qaoturi stili, SeiZleba Candnen araorganizebulebad da miiRon daniSnulebis gareSe wamlebi an alkoholi, raTa gamovidnen mdgomareobidan 15 . maT xSirad aqvT iseTi asocirebuli fsiqiatriuli Tanmxlebi daavadebebi, rogoricaa depresia, SfoT-viTi aSliloba, bipolaruli aSliloba, narkotikebis borotad gamoyeneba an swavlis dros aTvisebis sirTuleebi15. ADHD-s diagnozis dasma SeiZleba daexmaros mozrdilebs daakvirdnen, Cawv-dnen Tavis qcevas da xels uwyobs pacientebs gaxdnen ufro gaTviTcnobierebulni da eZebon gamosavali sirTuleebis daZlevis da mkurnalobis strategiebSi14. arsebobs garkveuli uTanxmoeba zogierT eqsperts Soris, gvxvdeba Tu ara ADHD mozrdil asakSi. 1978 wels mozrdilebSi misi arsebobis aRmoCenis Semdeg, is amJamadac ar aris erTmniSvnelovnad dakavSirebuli bavSvobaSi arsebul ADHD-sTan15. im winaaRmdegobebs Soris, romlebsac klinicistebi awydebian mozrdilebTan ADHD-s diagnozis dadgenisas, aris ganviTarebasTan Seusabamo diagnostikuri kriteriumebi, asakTan dakavSirebuli cvlilebebi, Tanmxlebi

4

daavadebebi da imis SesaZlebloba, rom maRal inteleqts an situaciur faqtorebs SeuZliaT daCrdilon ADHD-s simptomebi.

gaidlainSi gamoyenebuli Semoklebebi

ADHD

–

yuradRebis deficiti/ hiperaqtiuri

sindromi.

ICD 10

–

daavadebaTa da maTTan dakavSirebuli

janmrTelobis problemebis saerTaSoriso

statistikuri klasifikaciis meaTe

gadaxedva.

DSM-IV

–

fsiqiuri darRvevebis diagnostikuri da

statistikuri saxelmZRvanelos meoTxe

gamocema.

FDA – wamlebis federaluri sammarTvelo

AACAP _ bavSvTa da mozardTa fsiqiatriis amerikis

akademia.

AAP _ amerikis pediatriis akademia.

2. epidemiologia

ADHD (yuradRebis deficiti, hiperaqtivobis sindromi DSM-IV-is gansazRvrebiT, hiperkinetikuli aSliloba ICD-10-is gansazRvrebiT) farTodaa gavrcelebuli. gaerTianebul samefoSi 10.438 bavSvze (5 wlidan 15 wlamde asakis) Catarebulma kvlevam daadgina, rom biWebis 3,62% da gogonebis 0,85%-s aqvs ADHD

16.

aSS-Si Catarebuli erT-erTi kvlevis mixedviT dafiqsirda mcire, Tumca mniSvnelovani cvlilebebi daavadebis gavrcelebis doneSi afroamerikelTa (5,65%), laTinoamerikelTa (3,06%) da TeTrkanianTa (4,33%) Soris 17 , Tumca, aseTi gansxvavebebi SeiZleba aixsnas sxvadasxvanairi kulturuli tolerantobiT ADHD-is simptomebis mimarT.

sistemuri metaregresiuli analizis Sedegebis mixedviT 18 ADHD-s gavrcelebis variabelobis ZiriTadi ganmapirobebelia gamoyenebuli meTodologia, kerZod, simptomebis Sefasebis meTodebisa da gansazRvrebebis araidenturoba.

5

ADHD mozrdilebs Soris

ADHD-s gavrceleba iklebs asakTan erTad. bavSvobaSi ADHD-is diagnozis mqone individebTa monacemebis xangrZlivma bolodroindelma kvlevebma aCvena, rom 25 wlis asakSi mxolod 15%-s unarCundeba sruli ADHD diagnozi, magram, gacilebiT didi nawili (65%) akmayofilebs an ADHD-s anda ADHD-s nawilobriv remisiis kriteriumebs, rac SemTxvevaTa umravlesobaSi miuTiTebs klinikuri gaumjobesebis fonze garkveuli simptomebis mdgradobaze19. Tu mivusadagebT am cifrebs daavadebis gavrcelebis diapazons 4-8%, romelic zogadad SeiniSneba bavSvebSi, mosalodnelia, rom mozrdilTa 0,6-1,2%-Si 25 wlis asakSi SenarCunebuli iqneba ADHD-s sruli diagnozi. ufro didia ADHD-s nawilobrivi remisiis SenarCunebis procenti (2-4%). es Seesabameba mozrdilTa populaciaSi Catarebul mosaxleobis kvlevas, romelic afasebs ADHD-s gavrcelebas mozrdilebSi 3-dan 4%-mde20.

prognozi

bavSvebs, romlebsac daesvaT ADHD-s diagnozi, miuxedavad mkurnalobisa. aqvT seriozuli sirTuleebi mozardobis asakSi 21 . aSS-Si, ADHD-s mqone bavSvTa 37% ar Rebulobs saSualo skolis diploms, miuxedavad imisa, rom bevri maTgani sargeblobs damatebiTi saganmanaTleblo momsaxurebiT9, ADHD-s mqone moswavleTa TiTqmis naxevari ver amTavrebs saSualo skolas22. aseve, aSS-Si, ADHD-s mqone individTa 5%-ze naklebi Rebulobs kolejis (umaRlesi saswavlo dawesebulebis) diploms, rac sakmaod dabali maCvenebelia ZiriTadi mosaxleobis 28%-Tan SedarebiT23 . bavSvobaSi ADHD-s mqone adamianebi arian arasasurveli sayofacxovrebo SemTxvevebis maRali riskis qveS maSin, roca xdebian Tineijerebi. am SemTxvevebs Sorisaa avtokatastrofebi, travmebi, maRali samedicino xarjebi, wamaldamokidebuleba, adreuli seqsualuri aqtiuroba da mozard asakSi orsulobis ufro maRali riski1. ADHD-is diagnostikuri kriteriumebis mqone bavSvebis wili mcirdeba daaxloebiT 50%-iT diagnozis dasmidan 3 wlis Semdeg. es xdeba miuxedavad imisa, Tu ra mkurnaloba aris gamoyenebuli da aseve xdeba ADHD-s mqone aranamkurnaleb bavSvebSic 24 , 25 , 26 . daavadebul pirebTan, maT momwifebasTan erTad, viTardeba sirTulis daZlevis meqanizmebi da xdeba maTi adrindeli ADHD-is kompensacia15.

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3. etiopaTogenezi

etiologia

ADHD-s diagnozi ar gulisxmobs samedicino an nevrologiur mizezs. Tumca, fsiqosocialuri araxelsayreli faqtorebis arsebobam an risk-faqtorebmac ar unda gamoricxos ADHD-s diagnozi. ADHD-s etiologia moicavs mravali genetikuri da garemo faqtoris urTierTqmedebas. ADHD ganixileba, rogorc sxvadasxva qvetipebis mqone heterogenuri aSliloba, romelic erToblivad moqmedi risk-faqtorebis sxvadasxva kombinaciis Sedegia.

genetikis zegavlena

ADHD-s ganviTarebisaTvis mniSvnelovania genetikuri faqtorebi. ormagi kvlevis Sedegebi gviCvenebs, rom mosaxleobaSi arsebuli ADHD-s sindromebis variaciis daaxloebiT 75% gamowveulia genetikuri faqtorebiT^(memkvidreobiTobis Sefaseba 0,7-dan 0,8-mde)27. ADHD-Si identificirebuli araa arc erTi didi efeqtis mqone geni; ufro savaraudoa, rom masTan mcire efeqtis mqone ramodenime dnm-is variaciaa asocirebuli (TiToeuli mcire raodenobiT zrdis ADHD-s mimarT mgrZnobelobas).

mkvlevarebi Tvlian, rom ADHD-is SemTxvevaTa didi umravlesoba ganpirobebulia sxvadasxva genebis kombinaciiT, romelTaganac bevri dofaminis gadamtania. Sesaferis genebs Soris arian dofaminis gadamtani receptori D4, dofamin beta-hidroqsilaza, monoamin oqsilaza A, kateqolamin-meTil transferaza, serotoninis gadatanis xelSemwyobi (SLC6A4), 5-hidroqsitriptamin 2A receptori (5-HT2A), 5-hidroqsitriptamin 1B receptori (5-HT1B)28, DAT1 genis 10-jer gameorebuli aleli 29 , DRD4 genis 7-jer gameorebuli aleli da dofamin beta hidroqsilazas geni (DBH Taq1)30.

zemoT aRniSnuli CamonaTvali migvaniSnebs, rom ADHD ar imeorebs `genetikuri daavadebebis~ tradiciul models da Sesabamisad, unda ganxilul iqnes, rogorc genetikuri da garemo faqtorebis kompleqsuri urTierTqmedebis Sedegi. miuxedavad imisa, rom yvela am gens SeuZlia Tavisi roli Seasrulos, dRemde ar aris dadasturebuli, rom romelime calkeul gens yvelaze didi wvlili Seaqvs ADHD-s ganviTarebaSi31.

7

garemo faqtorebis zegavlena

dRemde Catarebuli ormagi kvlevebi aseve gvaCveneben, rom hiperaqtiuri-impulsuri-uyuradRebo qcevis an ADHD-s simptomebis variaciis daaxloebiT 9-dan 20%-mde SeiZleba mieweros garemo (aragenetikur) faqtorebs32,33.

biologiuri faqtorebi

faqtorebis mTeli diapazoni, romelic uaryofiTad moqmedebs Tavis tvinis ganviTarebaze perinatalur periodSi da adreul bavSvTa asakSi, asocirebulia ADHD-s riskis gazrdasTan, anu yuradRebis deficitis aSlilobasTan hiperaqtivobis gareSe. es faqtorebi moicavs dedis mier orsulobis dros sigaretis mowevas 34 , alkoholis moxmarebas 35 da heroinis moxmarebas 36 , dabadebisas nayofis Zalian mcire wonas, 37 , nayofis hipoqsias, Tavis tvinis dazianebas, toqsinebis zemoqmedebas, rogoricaa tyvia da cinki 38 . risk-faqtorebi ar moqmedeben izolirebulad, aramed urTierTqmedeben erTi meoresTan.

dakvirvebiT dadgina, rom ADHD-is pacientebs Tavis tkivilebis sixSire saSualoze ufro maRalia39, Tumca, amJamindeli faqtebi ar miuTiTeben imaze, rom dakvirvebis qveS myof pacientebSi Tavis tkivilebi SeiZleba iyos ADHD-s mizezi 40.

arsebobs ADHD-s simptomebis warmoSobis gazrdili riski: epilefsiis dros, genetikuri daavadebebis dros, rogoricaa 1 tipis neirofibromatozi 41 da iseTi sindromebi, rogoricaa angelmanis, prader-vilis, smiT magenisis, myife X-qromosomis sind-romi42 . meoradi ADHD SeiZleba gamoiwvios Tavis tvinis travmulma dazianebam43.

dietasTan dakavSirebuli faqtorebi

zogierTi bavSvis SemTxvevaSi eWvoben, rom dieta TamaSobs rols ADHD-s mravali qceviTi da SemecnebiTi simptomebis ganviTarebaSi. yuradReba gamaxvilebulia sakveb danamatebze, sisxlSi Saqris regulirebaze, kvebiT alergiaze, aseve vitaminebis, mineralebis da cximis mJavis deficitzeError! Bookmark not defined..

dietasTan dakavSirebuli faqtorebis zegavlenam ADHD-ze farTo sajaro interesi gamoiwvia: sakvebi danamatebi, Saqari, saRebavi nivTierebebi da `E~ ricxvebi xSirad ganixileboda, rogorc ADHD-s mizezi. xSirad profesiuli rCevis gareSec ki, farTod gamoiyeneba dietebi kvebiTi danamatebiT.

epidemiologiuri kvlevebi migvaniSnebs dietisas gamoyenebul danamatebsa da konservantebs da hiperaqtivobis dones Soris

8

arsebul kavSirze 44 , monacemebi sarwmuno ar aris, magram ADHD-s mqone bavSvebis mcire nawili amJRavnebs idiosinkreziul reaqcias zogierT naturalur sakveb produqtze da/an xelovnur danamatebze, da SeiZleba maTTvis daxmarebis gaweva gamoyenebuli konservantebisa da danamatebis gamoricxvis xarjze.

fsiqosocialuri faqtori

kvlevebiT miRebuli ar aris damajerebeli mtkicebulebebi, rom mxolod socialurma faqtorebma SeiZleba gamoiwvion ADHD-i9. rigi kvlevebiT dasturdeba, rom momvlelebis urTierTobas bavSvebTan SeuZlia Zlieri moqmedeba moaxdinos yuradRebis da TviTregulirebis SesaZleblobebze, Tumca monacemebi calsaxa ar aris.Error! Bookmark not defined.,45.

darRveuli da Seusabamo urTierTobebi ufro Cveulia ADHD-s mqone axalgazrduli ojaxebisaTvis 46 . Seusabamo ojaxuri urTierTobebi, SeiZleba, iyos amave dros ADHD-s mqone bavSvTan cxovrebis Sedegic. damkvidrebuli ADHD-is dros mkacri aRzrdis wesis momcveli urTierTobebi warmoadgens qcevasTan dakavSirebuli problemebis ganviTarebis risk-faqtors. mSoblebis mimarT mtruli ganwyobileba da kriticizmi SeiZleba Semcirdes im bavSvebSi, romelTa ADHD-s simptomebi warmatebulad iqna gankurnebuli stimulatorebis meSveobiT 47 . mSoblebs SeiZleba Tavadve hqondeT daudgeneli da arakontrolirebuli ADHD, rac araxelsayrelad imoqmedebs maT SesaZleblobaze gauwion daxmareba qcevis aSlilobis mqone bavSvs.

nevrologiuri Teoriis nairsaxeoba

am Teoriis momxreebi amtkiceben, rom atipuri nevrologiuri ganviTareba aris gansxvaveba, romelic tolerantulad unda iqnes miRebuli da romelsac pativi unda eces iseve, rogorc sxva adamianur gansxvavebulobas.

dabali aqtivaciis Teoria

dabali aqtivaciis Teoriis mixedviT, ADHD-s mqone adamianebi iyeneben TviTstimulacias da cdiloben iyvnen gadametebulad aqtiurebi, raTa aamaRlon Tavisi aranormalurad dabali aqtivaciis mdgomareoba 48 . am Teoriis mixedviT isini, visac ADHD aqvT, ver axerxeben TviTSekavebas da maTi yuradReba SeiZleba mipyrobil iqnas mxolod garemo stimulatorebze, rac Tavis mxriv gamoixateba sabolood yuradRebis gamaxvilebis SesaZleblobis darRvevaSi da hiperaqtiuri qcevis momatebaSi.

9

garemodan miRebuli sakmarisi stimulirebis gareSe, ADHD-s mqone bavSvi TviTon qmnis amas bodialis, mousvenari moZraobis, laparakis da a.S. xarjze. es Teoria aseve xsnis, Tu ratom aqvT stimulator medikamentebs esoden maRali samkurnalo efeqti da Terapiuli dozebSi SeuZliaT gamoimuSaon damSvidebis efeqti ADHD-s mqone bavSvebSi. es Teoria mWidro kavSirSia mecnierul monacemebTan, rom ADHD dakavSirebulia neiroqimiuri dofaminis anomaliebTan48.

paTfiziologia

ADHD-s paTfiziologia naTeli ar aris da arsebobs ramodenime urTierTgamomricxavi Teoria 49 . ADHD-s mqone bavSvebis erT-erTma kvlevam aCvena Tavis tvinis moculobis, zogadi Semcireba, magram is proporciulia marcxena mxaris Subliswina Tavis tvinis qerqis moculobis didi Semcirebisa. es aRmoCenebi gvimtkicebs, rom ADHD-s ZiriTadi Taviseburebebi (uyuradReboba, hiperaqtivoba, impulsuroba) SeiZleba gamoxataven frontaluri Sublis disfunqcias, magram Tavis tvinis sxva ubnebi, gansakuTrebiT naTxemi, aseve Cabmulia amaSi 50 . ADHD-s neirovizualuri kvlevebi yovelTvis ar iZlevian Tanmimdevrul Sedegs, da 2008 wlisTvis isini gamoiyeneboda mxolod kvlevisTvis da ara diagnostikuri mizniT51.

erT-erT kvlevaSi, dawyebiTi skolis asakis ADHD_s pacientebSi, Tavis tvinis centraluri struqturis ganviTarebis Seferxeba saSualod sami wlis ganmavlobaSi xdeboda. Seferxeba yvelaze mniSvnelovnad iyo gamoxatuli Tavis tvinis Sublis qerqsa da safeTqlis nawilSi, romelic rogorc cnobilia, agebs pasuxs azrovnebis kontrolsa da fokusirebaze. sapirispirod, ADHD-s mqone pacientebSi Tavis tvinis qerqis “moZraobis zonis” ufro swrafi momwifeba SeiniSneboda, vidre Cveulebrivad xdeba, ris gamo SeiZleba vivaraudoT, rom qcevis kontrolis ufro neli ganviTareba, aseve, motorikis ufro swrafi ganviTareba SeiZleba iwvevdes met mousvenrobas - hiperaqtivobas, rac damaxasiaTebelia ADHD-sTvis52.

imave laboratoriaSi manamde iyo aRmoCenili dofamin D4 receptori genis `7-jer ganmeorebuli~ variantis monawileoba, romelic pasuxs agebs ADHD-s genetikuri riskebis daaxloebiT 30%-ze, Tavis tvinis qerqis marjvena nawilis uCveulo Seviwrovebaze, Tumca, ADHD-s mqone pacientebSi aRmoCenili genis sxva variantebis sapirispirod, am bavSvebSi aTi wlis ganmavlobaSi es nawili normalizdeboda, rac emTxveoda klinikur gaumjobesebas53.

10

amasTan erTad, gama-tomografiuli skanirebiT naCvenebia ADHD-s mqone adamianebSi sisxlis Senelebuli mimoqceva (rac mianiSnebs dabal nervul aqtivobaze) 54 da dofaminis koncentraciis mniSvnelovani momateba striatumSi, romelic pasuxs agebs winaswar dagegmvaze55,56.

4. klinikuri simptomatika

simptomebi

ADHD-isTvis damaxasiaTebelia Semdegi simptomebi:

uyuradReboba

hiperaqtivoba

impulsuroba

uyuradReboba, hiperaqtivoba da impulsuroba warmoadgenen ADHD-s damaxasiaTebel qceviT maneras. ADHD-s simptomebis identificireba sakmaod rTulia imis gamo, rom saWiroa gansazRvra, Tu sad mTavrdeba uyuradRebobis, hiperaqtivobisa da impulsurobis normaluri done da iwyeba klinikurad mniSvnelovani done, romelic saWiroebs intervencias.

ADHD-s qvetipebi

ADHD-s sami qvetipi gaaCnia:

1. upiratesad hiperaqtiur-impulsuri;

simptomTa umetesoba (eqvsi an meti DSM-IV kriteriumebidan) aris hiperaqtiur-impulsuri kategoriis;

uyuradRebobis eqvsze naklebi simptomia saxeze, Tumca garkveulwilad SeiZleba iyos ganxiluli uyuradRebobac.

2. upiratesad uyuradReboba;

simptomTa umetesoba (eqvsi an meti DSM-IV kriteriumebidan) aris uyuradRebobis kategoriis;

arsebobs hiperaqtivoba-impulsurobis eqvsze naklebi simptomi, Tumca garkveulwilad SeiZleba iyos warmodgenili hiperaqtivoba-impulsurobac.

am qvetipis mqone bavSvebi naklebad axerxeben Tavis moCvenebas, aqvT sirTuleebi sxva bavSvebTan Seguebisas. isini SeiZleba Cumad isxdnen, magram sulac ar aqceven yuradRebas imas, Tu

11

ras akeTeben. Sesabamisad, aseT bavSvebs SeiZleba arc ki mieqces yuradReba, da mSoblebma da maswavleblebma SeiZleba verc ki SeamCnion ADHD-s simptomebi.

3. kombinirebuli hiperaqtiur-impulsuri da uyuradReboba.

saxezea rogorc uyuradRebobis aseve hiperaqtivoba-impulsurobis eqvsi an meti simptomi (DSM-IV kriteriumebidan);

bavSvTa umravlesobas ADHD-s kombinirebuli tipi gaaCnia.

qvemoT CamoTvlilia uyuradRebobisa da hiperaqtivoba-impulsurobis damaxasiaTebeli simptomebi:

1. upiratesad uyuradRebobis:

yuradRebis advilad gadatana, detalebis gamotoveba, sagnebis daviwyeba, xSiri gadarTva erTi aqtiurobidan meoreze.

erT rameze fokusirebis (koncentrirebis) siZneleebi.

raime amocanis gadawyvetisas sul raRac wuTebSi mowyenas, maSinac ki, rodesac isini raRacas gasarTobs akeTeben.

sirTuleebs raime amocanis organizebasa da dasrulebaze yuradRebis fokusirebisas da raime axlis swavlebisas.

problemebs saSinao davalebebis Sesrulebisas an Cabarebisas, im sagnebis (magaliTad, fanqrebi, saTamaSoebi, davalebebi) xSir dakargvas, romlebic saWiroa amocanis an saqmianobis dasrulebisaTvis.

saubris dros mosmenis naklebobas (TiTqos ar usmenen mosaubres).

ocnebas, advilad dabnevas da nel moZraobas.

sirTuleebs informaciis ise swrafad da akuratulad damuSavebisas, rogorc amas sxvebi axerxeben.

sirTuleebs instruqciebis midevnebisas.

2. upiratesad hiperaqtiur-impulsurobis;

mousvenrad moZraobas da trials Tavis skamze.

saubars gaCerebis gareSe.

swraf moZraobas aqeT-iqiT, mxedvelobis areSi myofi yvelas da yvelafris Sexebas da TamaSs.

12

problemebs adgilze jdomasTan dakavSirebiT sadilis dros, skolaSi an moyolis dros.

mudmivad moZraobaSi yofnas. sirTuleebs raime amocanisa an saqmianobis wynarad keTe-bisTvis.

am qvetipSi, zemoxsenebulis garda, upiratesad impulsuri xasiaTis simptomebs miakuTvneben:

arian Zalian mouTmenelni.

wamoroSaven Seusabamo komentarebs, amJRavneben Tavis emociebs yovelgvari moridebis gareSe da moqmedeben mosalodneli Sedegis gaTvaliswinebis gareSe.

aqvT sirTuleebi sasurveli sagnebis molodinisas an Tama-Sisas Tavisi rigis lodinisas.

adamianTa umetesoba amJRavnebs xolme zogierT aseT qcevas, magram ara im doneze, rodesac amgvari qceva mniSvnelovnad xels uSlis adamianTa saqmianobas, urTierTobas an swavlas. ZiriTadi darRvevebi Sesabamisi da erTnairia, sxvadasxva kulturul konteqstSic ki.

simptomebi SeiZleba arsebobdes mozrdil asakSic ADHD-s diagnozis mqone bavSvTa naxevarze metSi. amisi dadgena rTulia, vinaidan mozrdilTaTvis ar arsebobs ADHD-s aRiarebuli sadiagnozo kriteriumebi.

ADHD-s simptomebi da Tanmxlebi aSlilobebi

ADHD-s SeiZleba Tan axldes sxva aSlilobebs, rogoricaa SfoTva an depresia. aseT kombinaciebs SeuZliaT Zlier gaarTulon diagnozis dasma da mkurnaloba. akademiurma da kerZo praqtikis kvlevebma daadgines, rom ADHD-s dros bavSvebSi asakis matebasTan erTad matulobs depresiis SemTxvevebi, Tanac igi gogonebSi ufro maRali siCqariT izrdeba, vidre biWebSi, da gansxvavdeba gavrcelebaSi ADHD-s qvetipebis mixedviT. rodesac xasiaTis aSliloba arTulebs ADHD-s, ufro mizanSewonili iqneboda Tavdapirvelad xasiaTis aSlilobis mkurnaloba, magram ADHD-s mqone bavSvebis mSoblebs xSirad surT, rom Tavidan jer ADHD iyos gankurnebuli, vinaidan mkurnalobis Sedegi ufro swrafia.

uyuradReboba da `hiperaqtiuri~ qceva sulac araa erTaderTi problema ADHD-is mqone bavSvebSi. mravali Tanaarsebuli daavadeba moiTxovs mkurnalobis sxva kursis Catarebas da maTTvis diagnozi cal-calke unda daisvas, imis nacvlad, rom yvela erTbaSad

13

dajgufebuli iyos ADHD-is diagnozis qveS. qvemoT CamoTvlilia uxSiresi asocirebuli daavadebebi:

opoziciur-devianturi qceviTi aSliloba - negatiuri da mavne qcevebis gamovlineba socialuri normebis darRvevis gareSe

(35%);

qceviTi aSliloba (26%), romelic xasiaTdeba antisocialuri

qceviT, rogoricaa jiutoba, agresia, gaRizianebis xSiri

afeTqebebi, orpiroba, tyuilebis Tqma an qurdoba;

yuradRebis pirveladi aSliloba, romelic xasiaTdeba susti

yuradRebiT da koncentraciiT, da aseve fxizlad yofnis

sirTuleebi. aseTi bavSvebi ixrebian mousvenrad moZraobisken,

xSirad amTqnareben da izmorebian, cdiloben bevri imoZraon,

raTa aqtiurebi da fxizlebi gamoCndnen.

xasiaTis aSliloba _ kombinirebuli qvetipis diagnozis mqone

biWebi ufro savaraudod ganicdian zians xasiaTis

aSlilobisagan;

bipolaruli aSliloba - ADHD-s mqone bavSvebis aranakleb

25% aqvT bipolaruli aSliloba. aseTi kombinaciis mqone

bavSvebma SeiZleba gamoamJRavnon meti agresia da qcevasTan

dakavSirebuli problemebi, vidre im bavSvebma, romlebsac

mxolod ADHD-i aqvT;

SfoTviTi aSliloba, romelic, rogorc aRmoCnda, ufro

gavrcelebulia gogonebSi, romlebsac daesva ADHD-s

uyuradRebobis qvetipis diagnozi;

obsesiur-kompulsuri aSliloba - varaudoben, rom obsesiur-

kompulsuri aSliloba iziarebs genetikur komponents ADHD-

sTan da mis mraval maxasiaTebels.

ADHD-Tan asocirebuli gavrcelebuli problemebi:

xSirad ADHD-is problemebi bavSvebSi warmodgenilia ganviTarebasTan dakavSirebul sxva sisustesTan, naklTan da/an fsiqikur problemebTan erTad. arsebobs sakmaod araspecifikuri, zogadi problemebi, romlebic Zalian xSiria yuradRebis deficitisagan gamowveuli hiperaqtivobis aSlilobis dros da romlebic arasworadac ki SeiZleba iyos gamoyenebuli, rogorc diagnozis dasmis safuZveli (ix. cxrili 1).

amdagvar problemebs sWirdebaT amocnoba da zogjer Careva, magram miuxedavad amisa, aseTi problemebi TavisTavad mainc ar warmoadgenen diagnozis safuZvels, radganac isini SeiZleba

14

gamowveulni iyvnen sxva mravali mizeziT. amasTanave, mozardebma, iseve rogorc zrdasrulma adamianebma, SeiZleba gamoamJRavnon sxva asocirebuli problemebi, magaliTad rogoricaa sakuTari Tavis daSaveba, sagzao avariebisadmi midrekileba, nivTierebebis an wamlebis aramiznobrivad miReba, danaSaulebrioba, aforiaqebuli, mSfoTvare mdgomareoba da cudi akademiuri moswreba da swavla. TavisTavad zemoT CamoTvlili problemebi ar warmoadgens diagnozis safuZvels da SeiZleba gamowveuli iyos ADHD-iT an romelime sxva mizeziT.

cxrili 1. ADHD-Tan asocirebuli gavrcelebuli problemebi.

urCi, aradamyoli qceva. Uuneblie tikebi

cudi, mSfoTvare Zili Gganwyobilebis uecari

cvalebadoba

agresia TanatolebTan Seuguebloba,

konfliqti

Wirveuli xasiaTis

gamovlinebebi, isterikebi

mouxerxebloba

wera_ kiTxvis swavlaSi

problemebi da swavlasTan

dakavSirebuli sxva sirTuleebi

asakTan Seuferebeli,

CamorCenili metyveleba.

asakis matebiT ganpirobebuli cvlilebebi.

ADHD-sTan dakavSirebuli problemebi sxvadasxva asakSi sxvadasxva formiT iCens Tavs. cvlilebebi qcevaSi aRiniSneba individis Camoyalibebis, simwifis etapebis miRwevis paralelurad da imis mixedviT, Tu ra moTxovnebs ayenebs gare samyaro individis mimarT57. hiperaqtivoba skolamdeli asakis bavSvSi SeiZleba vlindebodes misi moqmedebebis ganuwyvetel da momTxovn ukiduresobebSi; skolis periodSi aseTi bavSvi SeiZleba aRmoCndes gadametebulad moZravi iseT situaciaSi, sadac, wesiT, simSvide da mSvidi moqmedebaa ufro mosalodneli, Tumca aseTi qceva SeiZleba ar aRiniSnebodes sistematurad, yovelTvis erTnairi aRznebadobiT ar vlindebodes msgavs situaciebSi. mozardobis periodSi hiperaqtivoba SeiZleba iyos gamoxatuli ara mTeli sxeulis moZraobiT, aramed raRac mousvenari saqcieliT, cqmutviT, wrialiT. ukve zrdasrulobis asakSi ki es aSliloba SeiZleba gamoixatos mudmivi Sinagani mousvenrobis, foriaqis mZafri SegrZnebiT. Aaseve SeiZleba Tavad yuradRebis deficitis zRvarmac daiwios da asakis matebasTan erTad koncentraciis unaris xangrZlivobac gaizardos. Tumca,

15

aseTi koncentraciis unari mainc CamorCeba am aSlilobisgan Tavisufali adamianebis koncentraciis unars da mainc rCeba im zRvars miRma, romelic saWiroa adamianis yoveldRiurobaSi garkveuli warmatebebis misaRwevad.

5. daavadebis diagnozi

klinikuri manifestacia

Cveulebriv, bavSvi ADHD ojaxis eqimTan xvdeba maswavleblis an mSoblebis moTxovniT, mas Semdeg, rac ufrosebi uZlurni xdebian gaakontrolon da marTon bavSvis qceva. diagnozis dasasmelad aucilebelia srulyofili informaciis mopoveba bavSvis arastandartuli qcevis Sesaxeb ara mxolod ojaxis wevrebisagan, aramed sxva mozrdilebisganac, romlebic axlos arian bavSvTan (C). informaciis Sekrebis Sesaxeb AAP da AACAP –s rekomendaciebi mocemulia me-2 cxrilSi 58 , 59 . diagnozis dasasmelad informaciis Segrovebis Semdeg aucilebelia bavSvze dakvirveba da sruli fizikuri gamokvleva.

cxrili 2 ADHD-ze saeWvo bavSvis gamokvleva (AAP-isa da AACAP –is kombinirebuli rekomendaciebi) 58,59.

rekomendacia 1

pirveladi jandacvis eqimma unda daiwyos gamokvleva ADHD-ze 6-dan 12 wlamde asakis im bavSvebTan, romelTac aReniSnebaT hiperaqtiuloba, impulsuroba, dabali akademiuri moswreba an qceviTi problemebi.

sawyisi Sefaseba unda moicavdes:

standartuli anamnezi da fizikuri gamokvleva, AACAP-is rekomendaciiT bavSvis ganviTarebis istoriis Sefaseba, smenis, mxedvelobis, swavlis problemis, fsiqiatriuli daavadebisa da ADHD-s ojaxuri istoriis gamokvleva;

nevrologiuri gasinjva;

ojaxis Sefaseba – AACAP-is rekomendaciiT ojaxuri stres-faqtorebisa da ojaxis mfarvelobiTi rolis Sefaseba;

skolis Sefaseba (ix. rekomendacia 4).

rekomendacia 2

ADHD-is diagnozis dasasmelad aucilebelia, rom

simptomatika akmayofilebdes DSM-IV kriteriumebs.

16

rekomendacia 3

ADHD-s Sesafaseblad aucilebelia piradad mSolebis an momvlelis mier ADHD-s ZiriTad simptomebis calsaxad dadastureba sxvadasxva garemoSi/adgilebSi, simptomebis aRmocenebis asaki, simptomebis xangrZlivobas da funqciuri CamorCenis xarisxis aRwera.

rekomendacia 4

ADHD-s Sesafaseblad aucilebelia skolis maswavleblis (damrigeblis an aRmzrdelis) mier ADHD-s ZiriTad simptomebis calsaxad dadastureba, simptomebis xangrZlivobisa da funqciuri CamorCenis xarisxis aRwera. eqimma yuradRebiT unda Seiswavlos bavSvis skolis maswavleblis an skolis sxva profesionalis mier micemuli daxasiaTeba.

rekomendacia 5

ADHD-ze saeWvo bavSvis gamokvleva moicavs Tanmxlebi mdgomareobebis Sefasebas, rogoricaa – swavlis da metyvelebis problemebi, SfoTva, depresia da a.S.

rekomendacia 6

diagnostikuri testebi, magaliTad, tyviis gansazRvra, TSH-is gansazRvra, eleqtroencefalograma, rutinulad rekomendebuli ar aris, tardeba mxolod Sesabamisi klinikuri Cvenebebis arsebobisas.

sadiagnozo kriteriumebi

ADHD-s diagnozi ismeba DSM-IV diagnostikur kriteriumebTan

(cxrili 3) Sesabamisobis SemTxvevaSi, rodesacError! Bookmark not

defined.

bavSvs aReniSneba uyuradRebobis an hiperaqtiulobis/

impulsurobis minimum 6 simptomi 9 CamoTvlilidan;

simptomebi aris aSkarad gamoxatuli da iwveven CamorCenas;

grZeldeba minimum 6 Tve;

dawyebulia 7 wlis asakamde;

vlindeba minimum 2 sxvadasxva socialur gareomoSi (mag.

skolaSi da saxlSi, an megobrebTan urTierTobisas).

17

cxrili N 3. ADHD-is sadiagnozo kriteriumebi DSM-IV:

I

A an B

uyuradRebobisa da hiperaqtiuloba/impulsurobis simptomebi

A

koncentraciis uunaroba – qvemoT CamoTvlilTagan eqvsi an meti simptomi unda vlindebodes sul mcire, 6 Tvis ganmavlobaSi im xarisxiT, rom mocemuli asakis bavSvs xels uSlides garemosTan SeguebaSi.

1. xSirad ver axerxebs miaqcios mkafio yuradReba detalebs an uSvebs daudevar Secdomebs skolis davalebebSi, saqmianobaSi an sxva saxis aqtivobebSi.

2. sirTuleebi sxvadasxva davalebebis Sesrulebisas an TamaSis dros yuradRebis garkveuli droiT daZabvisas.

3. xSirad Cans, TiTqos ar usmens masTan piradad mosaubres.

4. xSirad ar mihyveba da ar asrulebs micemul instruqciebs, ver axerxebs skolis davalebebis damTavrebas, ver arTmevs Tavs saojaxo an samsaxuris movaleobebs (yovelive es gamomdinareobs winaaRmdegobrivi qcevidan, an problemebi iqmneba instruqciis gagebaSi da mis SesrulebaSi).

5. xSirad aRiniSneba problemebi davalebebis da aqtivobebis organizebis sakiTxSi.

6. xSirad Tavs aridebs, ar moswons, an ar surs Seasrulos samuSao, romelic moiTxovs gonebis Zalisxmevas drois garkveuli monakveTis ganmavlobaSi.

7. xSirad kargavs nivTebs, romlebic saWiroa ama Tu im davalebisaTvis an aqtivobisaTvis.

8. advilad efanteba yuradReba araarsebiTi movlenebis, gare stimulis zemoqmedebiT.

9. xSirad aris gulmaviwyi yoveldRiuri davalebebis Sesrulebisas.

B

hiperaqtivoba-impulsuroba – qvemoT CamoTvlilTagan eqvsi an meti simptomi unda vlindebodes sul mcire, 6 Tvis ganmavlobaSi im xarisxiT, rom mocemuli asakis bavSvs xels uSlides garemosTan SeguebaSi.

18

hiperaqtivoba

1. xSirad mousvenrad amoZravebs xelebs, terfebs an cqmutavs da wrialebs skamze.

2. xSirad dgeba adgilidan saklaso oTaxSi an romelime sxva garemoSi, maSin, rodesac situaciidan gamomdinare, erT adgilze mSvidad jdoma aris saWiro.

3. xSirad uadgilod da umiznod darbis an cocavs gadametebuli aqtivobiT (mozardebsa da ufrosebSi gamoixateba mousvenrobis grZnobiT).

4. xSirad ver axerxebs mSvidad da Cumad TamaSs, garTobas an dasvenebas.

5. xSirad CarTulia aqtiur moqmedebebSi, adgilidan adgilze gadadis, TiTqos Zrava amoZravebs.

6. xSirad mometebulad bevrs laparakobs.

impulsuroba

7. xSirad wamoisvris pasuxs kiTxvis daboloebis dalodebis gareSe.

8. xSirad uWirs daelodos Tavis rigs.

9. xSirad uadgilod erTveba an awyvetinebs sxvebs ( mag. iWreba saubarSi an TamaSSi).

II

hiperaqtiur- mpulsuri an yuradRebis koncentraciis zogierTi simptomi, romelmac garkveuli Seferxeba gamoiwvia, bavSvs

aReniSneboda 7 wlis asakamde.

III

simptomebisagan gamowveuli SezRudvebi aRiniSneba or an met sxvadasxva garemoSi (mag. skolaSi, saTamaSo moedanze, saxlSi da a.S.)

IV

mniSvnelovani SezRudva/CamorCena calsaxad unda iyos gamoxatuli socialur, saskolo an samuSao garemoSi.

V

simptomebi ar vlindeba mxolod ganviTarebis procesSi wamoWrili aSlilobis, Sizofreniis an sxva fsiqiuri aSlilobis dros. Aam simptomebis ukeT axsna ar SeiZleba sxva fsiqiuri aSlilobebis gamovlinebebiT (rogoricaa mag. ganwyobilebis aSliloba, Sinagani SfoTva da foriaqi, asociaciuri aSliloba an pirovnuli aSliloba).

19

I suraTze mocemulia ADHD-s diagnostikis algoriTmi

suraTi 1 ADHD-s diagnostikuri algoriTmi

1

swavlis/qcevis problemebi,

saeWvo ADHD

12

ADHD diagnozis

formulireba

4

ADHD-s sakvanZo maxasiaTeblebis

gamokvleva DSM-IV DSM_PC kriteriumebis

gamoyenebiT:

simptomebi;

dasawyisi;

xangrZlivoba;

simptomebis arseboba sxvavdasxva

garemoSi;

CamorCena – gauareseba

(impairment)

10

akmayofilebs DSM-IV DSM_PC kriteriumebs?

8 aris romelime

asocirebuli

komorbiduli daavadeba?

6

savaraudoa Tu ara, rom

ADHD pirveladi diagnozia?

5

SeafaseT sxva pirveladi da komorbiduli

mdgomareobebis arseboba:

biosamedicino problemebi;

emociuri/fsiqiatriuli problemebi;

ojaxis/fsiqologiuri problemebi;

metyvelebis/enis problemebi;

akademiuri/swavlis problemebi.

2

krizisi?

3

dauyovneblivi

Sefaseba an/da

referali

11

saWiroebs

Semdgom

gamokvlevas. ar

Sedis mocemul

gaidlainSi

7

saWiroebs Semdgom

gamokvlevas, moaxdineT

koordinireba Sesabamis

specialistTan. ar Sedis

mocemul gaidlainSi

9

specialistis

konsultacia

dia

x

diax

ar

a

ara

diax

diax

diax

ara

ara

ara

20

algoriTmis zogierTi punqtis ganmarteba grafebis nomrebis mixedviT

1. swavlis/qcevis problemebi (saeWvo)

sakvanZo sakiTxebi:

bavSvi SesaZloa eqimTan mimarTon swavlisa da qcevis problemebis gamo, an konkretulad ADHD-s arsebobis gamosakvlevad.

ADHD-s simptomebis intensiuroba da mravalferovneba variabeluria bavSvis asakisa da akademiuri moswrebis mixedviT.

mSoblebis mier dafiqsirebuli SesaZlo problemebi:

TviTneboba;

agresia;

mrisxanebis marTvis problema;

impulsuroba;

fizikurad saxifaTo aqtivobebi;

davalebis dasrulebis problemebi;

araorganizebuloba;

gafantuloba, yuradRebis koncentraciis siZneleebi;

labiluri fsiqika;

ugunuroba;

socialuri/emociuri umwifroba;

gauTavebeli, “hiper” moZraobebi

maswavleblebis/skolis personalis mier dafiqsirebuli SesaZlo problemebi:

hiperaqtiuloba;

dauRalavi, SfoTviTi qceva;

uyuradReboba, davalebis ugulvelyofa, paTologiuri yuradRebis gafantuloba;

socialuri kavSirebis problema;

dabali akademiuri moswreba, skolis xSiri gacdena;

saklaso oTaxSi damangreveli qceva;

bevri saubari, pasuxebis wamoZaxeba, wamocdena;

cudi mosmena;

arasruli davalebebi da davalebebis arqona;

uwesrigo, qaosuri qceva

bavSvis/mozardis mier dafiqsirebuli SesaZlo problemebi:

ar uyvars skola;

ar SeuZlia axlo da xangrZlivi megobroba;

21

konkretuli maswavleblebisa da sagnebis siZulvili;

gadametebuli konfliqtebi mSoblebTan;

dabali TviTrwmena, dabali sakuTari Tavis pativiscema

asakTan da ganviTarebasTan erTad ADHD-s simptomebi ganicdis cvlilebas, magaliTad, mozardobis periodSi klebulobs motoruli hiperaqtivoba, spontanurad umjobesdeba yuradReba da ufro TvalsaCino xdeba antisocialuri qceva, SesaZloa problemebi kanonTan.

2. krizisi?

ADHD-is Sefasebis dawyebamde unda ganisazRvros, xom ar aris krizisuli situacia, romelsac dauyovneblivi Careva sWirdeba. aRniSnuli Sefaseba unda Catardes momarTvis adgilze – ofisSi, telefoniT, saswavlo dawesebulebaSi da a.S. krizisTan erTad SesaZlebelia ADHD-c aRiniSnebodes, Tumca am SemTxvevaSi ADHD-s marTva mogvianebiT unda daiwyos, krizisi saWiroebs dauyovnebliv reagirebas. krizisis arsebobis Sesafaseblad unda daisvas Semdegi SekiTxvebi:

aris suicidis saSiSroeba?

aris Zaladobis/fizikuri dazianebis saSiSroeba sxvebisaTvis? aris bavSvze Zaladobis saSiSroeba?

aris skolidan garicxvis saSiSroeba?

aris dapatimrebis/kanonTan problemebis Seqmnis saSiSroeba?

3. dauyovnebeli Sefaseba da/an referali

aRniSnuli mTlianadaa damokidebuli Sefasebis adgilze, konkretul situaciaze da SesaZlo resursebze. mag. es SeiZleba iyos vizitis dagegmva mentaluri janmrTelobis specialistTan, fsiqiatrTan, socialuri samsaxuris mobilizeba, saswrafo daxmareba da a.S. pirveladi jandacvis rgolSi unda moxdes krizisis arsebobis Sefaseba da saWiroebis SemTxvevaSi dauyovneblivi referali mesameul doneze (B, C, R).

4. ADHD-s sakvanZo maxasiaTeblebis gamokvleva DSM-IV

kriteriumebis gamoyenebiT:

pirveladi simptomebis Sesafaseblad aucilebelia

informaciis ramodenime wyaro: mSoblebi/momvleli, bavSvi,

skolis personali;

kriteriumebi dakavSirebulia problemis aRmocenebis asakTan,

xangrZlivobasTan, gavrcelebasTan (sxvadasxva garemoSi

22

gamovlena, mag-skola, saxli, amxanagebi) da CamorCenasTan.

maTi erTobliobiT SesaZloa daisvas ADHD-s diagnozi.

5. xva pirveladi da komorbiduli mdgomareobebis arsebobis Sefaseba – ix. Tavi 5.2. diferenciuli diagnozi.

Tu gamokvlevis periodSi gamovlinda alternatiuli pirveladi diagnozi, unda moxdes identificirebuli problemis Sesabamisi marTva (gaidlainis gareT).

diferenciuli diagnozi

ADHD-isaTvis damaxasiaTebeli simptomebi xSiria sxva fsiqiuri janmrTelobis problemebis dros. aqedan gamomdinare, eWvis dros gaTvaliswinebuli unda iyos rogorc yuradRebis deficitis an hiperaqtiuloba/impulsurobis gamomwvevi sxva daavadebebis arseboba, aseve komorbiduli aSlilobac. Ees orive faqtori, Tavis mxriv, mxedvelobaSia misaRebi.

ADHD-is mqone bavSvTa diferenciuli diagnozi da komorbiduli daavadebebis Sefaseba

qvemoTCamoTvlili xuTi sferos skriningi uzrunvelyofs monacemebs ADHD-s diferencialuri diagnozisaTvis.

1. biosamedicino problemebi:

2. emociur/fsiqiatriuli problemebi

3. ojaxuri/fsiqosocialuri problemebi;

4. metyvelebis/enobrivi problemebi;

5. akademiuri moswrebis / swavlebis problemebi

1. biosamedicino problemebi.

mTavari sakiTxebi:

aucilebelia anamnezisa da fizikuri/nevrologiuri/ganviTare-

bis Sefaseba, raTa identificirebul an gamoricxul iqnas

ADHD-is arseboba.

anamnezsa da samedicino Semowmebaze dayrdnobiT, SeiZleba

gansazRvrul iqnas Semdgomi klinikuri gamokvlevebi iseT

sferoSi, rogoricaa genetikuri (qromosomuri), nevrologiuri

an biosamedicino problemebi.

23

janmrTelobis istoria da fizikuri/nevroloiuri/ganviTarebis Sefaseba aucilebelia imisaTvis, raTa gansazRvrul an gamoricxul iqnas biosamedicino areSi ADHD-s diferencialuri diagnozis problemebi. sensorul sferoSi (anu smena da mxedveloba) problemebma SeiZleba gamoiwvion sirTuleebi saklaso oTaxSi, rac SeiZleba gamoixatos mousvenar an uyuradRebo qcevaSi. nevrologiuri Seferxebis an nevrologiuri `rbili niSnebis~ mqone bavSvebi swavlebis aTvisebasTan dakavSirebuli moSlilobebis da qceviTi moSlilobebis riskis qveS imyofebian60. (R)

zogadi janmrTelobis istoria da samedicino daTvaliereba gulisxmobs:

zrdis parametrebi: simaRle, wona;

ZiriTadi parametrebi: sisxlis wneva, pulsi;

mxedvelobis da smenis skriningi.

specialuri yuradReba unda gamaxvildes:

zogad fizikur ganviTarebaze

- mcire fizikuri anomaliebi SeiZleba iyos genetikuri anomaliebis, darRvevebis (dabla ganlagebuli yurebi, didi an saTesle parkebSi Camousvleli saTesle jirkvlebi, Zlier amozneqili sasa da a. S.) maniSnebeli;

wamaldamokidebulebis niSnebi da simptomebi;

nevrologiuri gamokvleva:

- darRvevebi (magaliTad, motoruli an metyvelebis dambla, refleqsebis asimetria, an anomalia, an tremori);

- odnav SesamCnevi nevrologiuri niSnebi, maT Soris sirTuleebi moqmedebebis Tanmimdevrobis gansazRvrasTan, aritmiasTan, sarkisebur gamosaxulebasTan, motorul siWarbesTan da mouqnelobasTan dakavSirebiT. `mouqnelobas~ ganekuTvneba zusti an zogadi (miaxloebiTi) samoZrao amocanebis Sesrulebis winaswari, neli, araregularuli an araTanmimdevruli moqmedebebi;

ganviTarebis statusis Sefaseba:

- bavSvebis aqtiurobis, saTanadod urTierTobis, miTiTebebis midevnebis SesaZleblobasa da TanamSromlobaze dakvirveba gamokvlevaTa kabinetSi;

Seferxebebis an problemebis istoria:

24

- smeniTi aRqma;

- eqspresiuli metyveleba;

- monacemTa vizualuri an Tanmimdevruli damuSaveba;

- mexsiereba;

- natifi da uxeSi motorika;

kognitiuri CamorCenis skriningi.

samedicino muSakma SeiZleba gamosadegad CaTvalos qvemoT CamoTvlili. pasuxi (reaqcia) asakzea damokidebuli.

- sTxoveT bavSvs isaubros bolodroindel movlenaze _ dabadebis dReze, sportul Sejibrebaze da a.S. (miaqcieT yuradReba, ramdenad Tavisufali, dalagebuli da orga-nizebulia misi metyveleba);

- hkiTxeT mSoblebs, aqvs Tu ara bavSvs sirTuleebi sate-lefono mesijebis miRebisas an saklaso oTaxSi miRebuli instruqciebis damaxsovrebisas, asakTan SesabamisobaSi (moklevadiani maxsovroba);

- daakvirdiT bavSvs, rodesac is iyenebs fanqars simboloebis an sityvebis gadawerisas (vizualuri percefciul-motoruli)

- sTxoveT bavSvs Seasrulos samsvliani brZaneba (moqmedebaTa Tanmimdebroba);

- sTxoveT bavSvs gaimeoros oTxi sityva, daimaxsovros isini da kidev erTxel gaimeoros, isini 5 an 10 wuTis Semdeg (maxsovroba, yuradReba);

- sTxoveT bavSvs gaimeoros sami, Semdeg oTxi cifri TanmimdevrobiT, Semdeg gaimeoros jer sami, xolo Semdgom oTxi cifri ukumimarTulebiT (koncentracia);

anamnezsa da samedicino daTvalierebaze dayrdnobiT, momdevno gamokvleva SeiZleba ganisazRvros iseTi sferoebiT, rogoricaa:

genetikuri an qromosomuli

o myife X sindromi o turetis sindromi

o mentaluri CamorCena o neirofibromatozi

nevrologiuri

o krunCxviTi aSliloba o cnsis infeqcia infeqcia

o qoreoformuli aSliloba o cns-is travma

o neirodegeneraciuli daavadebebi

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biosamedicino

o toqsinebi (tyvia, fetaluri alkoholuri sindromi, kokainis prenataluri zemoqmedeba);

o alergia;

o smeniTi an vizualuri darRveva;

o metaboluri/endokrinuli;

o anemia;

o Zilis moSlilobebma SeiZleba gamoiwvion iseTi qceva, romelic SeiZleba miemsgavsos msubuqi formis ADHD-s, da aseve gaamwvavos saSualo an Zlieri ADHD-s simptomebi. Zili guldasmiT unda iqnas Semowmebuli.61 (C)

mtkicebulebebis klasi C, D .

2. emociuri/fsiqiatriuli problemebi

mTavari momentebi:

ADHD-s mqone bavSvebs depresiis, SfoTviTi moSlilobebis, qceviTi moSlilobis da wamalTdamokidebulebis momatebuli riski aqvT;

klinicistebma yvela ADHD-s mqone pacientTan intervius dros unda gamoikvlion es Tanmxlebi daavadebebi;

autisturi speqtris moSlilobis mqone bavSvebs SeiZleba hqondeT ADHD-s simptomebis niSnebi, magram autisturi speqtris simtomebi unda CaiTvalos ZiriTadad.

ADHD-s diagnozis dasma SeiZleba garTulebuli iyos an sxva Tanarsebuli fsiqiatriuli daavadebis, an kidev, iseTi fsiqiatriuli daavadebis arsebobiT, romelsac ADHD-s damaxasiaTebeli simptomebi aqvs. rogorc cnobilia, yuradRebis deficitisa da hiperaqtivobis mqone bavSvebi imyofebian depresiis, SfoTviTi moSlilobebis, qceviTi moSlilobebis da wamalTdamokidebulebis momatebuli riskis qveS. am daavadebebis prevalirebis diapazoni ADHD-s mqone bavSvebSi 15-dan 30%-mdea. klinicistis movaleobaa, Caataros zemoTCamoTvlili oTxi daavadebis skriningi, rodesac amowmebs iseT bavSvs, roelsac aReniSneba ADHD-s simptomebi62.

mtkicebuleba C, R.

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qvemoT ganxilulia depresiis, SfoTviTi moSlilobebis, qceviTi

moSlilobebisa da wamalTdamokidebulebis SesaZlo arsebobis

damadasturebeli simptomebi.

depresia

mudmivi depresiuli an gaRizianebuli xasiaTi TiTqmis

yoveldRe, rac grZeldeba rogorc minimum ori kvira;

mniSvnelovnad Semcirebuli interesi an siamovneba yvela

an TiTqmis yvela saqmianobisgan;

saskolo davalebis an samuSaos Sesrulebis xarisxis

aSkara daqveiTeba;

drodadro ganmeorebiTi suiciduri azrebi raime

konkretuli gegmis gareSe, an periodulad ganmeorebiTi

fiqri sikvdilze;

mdgradi gauTavebeli depresiuli ganwyoba dakavSirebuli

TiTqmis yoveldRiur uZilobasTan an hipersomniasTan

(zedmetad momatebuli Zilianoba).

iuveniluri maniakalur-bipolaruli aSliloba

bolo drois gamocdileba gvaZlevs saSualebas vivaraudoT garkveuli Tanxvedra ADHD-sa da iuvenilur maniakalur-bipolarul aSlilobas Soris. qvemoT mocemuli warmoadgens sabavSvo periodis maniis maxasiaTebel niSnebs, ramac SeiZleba xeli Seuwyos klinicists am ori daavadebis diferencirebaSi:

maniakalur-bipolaruli aSliloba Zalzed iSviaTia, ADHD-sTan SedarebiT;

simptomebi moicavs afeqturi Setevebis swrafad gamoCenas, gaxangrZlivebul Zlier ganrisxebis afeTqebebs, gaafrTebul mZvinvare agresiulobas, gaRizianebadobas, cvalebad interpersonalur urTierTobas;

Cveulebriv, Tanaarsebobs depresiasTan erTad.

SfoTviTi aSliloba

posttravmuli stresuli aSliloba da SfoTviTi aSliloba 2 yvelaze gavrcelebuli mdgomareobaa, romelic SesaZloa ADHD-s msgavsi klinikiT mimdinareobdes. posttravmuli stresuli aSlilobis yvelaze gavrcelebuli mizezebia fizikuri da seqsualuri Zaladoba. Ffsiqologiuri anamnezi unda gamovikvlioT zedmiwevniT da unda ganvixiloT, rogorc mTliani Sefasebis

27

nawili. sxva diagnozebi, romlebic ufro saxezea sabavSvo asakSi, moicavs separaciuli gangaSis aSlilobas da generalizebul SfoTviT aSlilobas. skriningi, romelic SeiZleba gamosadegari iyos am daavadebebis identifikaciisas, mocemulia qvemoT.

ganviTarebis donesTan Seusabamo da gadametebuli SfoTva, romelic gamowveulia saxlisagan an im pirebTan daSorebiT, visTanac bavSvi miCveulia yofnas;

mudmivi an gadametebuli SfoTva Zalian axlobeli adamianebis dakargvis SiSisa da im savaraudo zianis gamo, romelic SeiZleba maT miadgeT;

ganmeorebadi Civili an fizikuri simptomebi, romelic dakavSirebulia axlobel adamianebTan ukve Semdgar, an mosa-lodnel daSorebasTan;

zedmeti TviTgvema dabali moswrebis gamo (magaliTad, skolaSi miRebuli Sefaseba);

bavSvisTvis rTuli xdeba misi SfoTvis/Sewuxebis gakon-troleba an SeCereba.

qceviTi aSliloba

negatiuri, mtruli da gamomwvevi qcevis arseboba, rac SeiZleba moicavdes mwyobridan gamosvlas, mozrdilebTan kamaTs, mozrdilebis moTxovnebis dakmayofilebaze (damorCi-lebaze) uaris Tqmas, ganzrax adamianebisTvis Tavis mobezrebas, mudmiv risxvas da sxvebis mimarT gamoxatul ukmayofilebas (gaRizianeba);

adamianebsa Tu cxovelebis mimarT fizikur agresia;

qurdobaSi ganzrax monawileoba;

potenciurad seriozuli SedegebiT dasrulebuli wesebis darRveva (magaliTad, saxlidan gaqceva, skolis gacdena);

qcevis darRveva iwvevs klinikurad minSvelovan darRvevas socialur, akademiur an SromiT saqmianobaSi.

wamaldamokidebuleba (narkomania/alkoholizmi)

alkoholis an nebismieri saxis dauSvebeli wamlebis (narkotikebis) gamoyeneba anamnezSi;

alkoholis an narkotikebis gamoyeneba ganwyobis Sesa-cvlelad an cudi ganwyobisgan Tavis dasaRwevad;

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problemebi skolaSi, saxlSi an kanonier xelisuflebasTan, romelic dakavSirebulia pacientis mier alkoholis an narkotikebis miRebasTan;

Tanatolebisagan miRebuli informacia pacientis mier alkoholis an narkotikebis moxmarebasTan dakavSirebiT;

alkoholis an narkotikebis moxmarebis gamo sakuTari Tavis dadanaSauleba;

qceva, romelic migvaniSnebs alkoholis an narkotikebis moxmarebaze (gazrdili izolacia ojaxisa da megobrebisagan, narkotikuli nivTierebebis misaRebi mowyobilobebis arseboba).

farTod gavrcelebuli, ganviTarebasTan dakavSirebuli moSli-lobebi (magaliTad, autisturi aSliloba, aspergeris sindromi)

arc Tu ise iSviaTad autisturi speqtris aSlilobis mqone bavSvebs saxeze aqvT ADHD-s damaxasiaTebeli niSnebi. am bavSvebisTvis tipiuri da problematuria:

sazogado urTierTobis xarisxobrivi gauareseba (mag. Tanaziaroba, araverbaluri Jestebi, erToblivi monawileoba saqmianobaSi, urTierToba TanatolebTan);

xarisxobrivi gauareseba komunikaciisas (mag. metyvelebis Seferxebebi, sasaubro metyveleba, idiosinkrazi-uli/stereotipuri metyveleba, simboluri/imitaciuri TamaSi);

qcevis SezRuduli, ganmeorebadi modeli (magaliTad, SeSfoTeba (winaswarSegoneba), ritualebi, TviT-stimulato-ruli motoruli manerizmi.

3. ojaxuri/fsiqologiuri problemebi

mTavari momentebi:

qronikulma an mwvave stresebma SeiZleba gamoiwvion cvlileba bavSvis akademiur moswrebaSi an qceviT funqcio-nirebaSi, rogoricaa ADHD-s simptomebis imitacia an arsebuli simptomebis gamwvaveba.

SeafaseT ojaxSi arsebuli fsiqikuri daavadebebis istoria. ADHD-s qvetipebi icvleba ojaxSi arsebuli fsiqikuri daavadebis tipis mixedviT.

SeafaseT ojaxis funqcionireba, momvlel pirsa da bavSvis urTierTobis bunebis, ojaxis SigniT simptomebis gavlenis da

29

problemis daZlevis ojaxSi arsebuli resursebis TvalsazrisiT.

garda Tanmxlebi fsiqiatriuli an swavlebis aTvisebasTan dakavSirebuli problemebis Sefasebisa, mniSvnelovania im fsiqo-logiuri konteqstis gaTvaliswineba, romelSiac aRmocendeba bavSvis simptomebi da problemebi. qvemoT identificirebulia gasaTvaliswinebeli faqtorebi da zogierTi mosazrebani intervius dros dasasmeli kiTxvebis Sesaxeb. ojaxis funqcionirebis guldasmiTi Sefaseba xels Segviwyobs bavSvTa simptomebis rogorc bunebisa, aseve simZimis gaTviTcnobierebaSi da agreTve ojaxis unaris gagebaSi gamoiyenos ganaTlebasTan da mkurnalobasTan dakavSirebuli rekomendaciebi. Tu saxezea mniSvnelovani ojaxuri paTologia, maSin aucilebelia mimarTva fsiqiatrTan, ojaxis eqimTan an socialur samsaxurebSi.

fsiqologiuri stresorebi

arsebobs garkveuli mtkicebulebebi (faqtebi) imisa, rom ADHD-s da erTdroulad moqmedi depresiuli an SfoTviTi daavadebebis mqone bavSvebs cxovrebiseuli stresebis da dedis mxridan arsebuli fsiqiatriuli simptomebis ufro maRali done aqvT63 (C).

qronikuli an mwvave stresebi bavSvis funqcionirebaSi SeiZleba sxvadasxva gziT gamomJRavndes; zogadi simptomebi moicavs SfoTvas, disforias (uxalisobas) da qceviT reagirebas. am sirTuleTagan nebismierma SeiZleba gamoiwvios akademiuri moswrebis an Sinaur garemoSi qcevis cvlileba.

stresiT aRsavse cxovrebiseuli movlenebi SeiZleba moicavdes:

did cxovrebiseul gardaqmnebs da cvlilebebs (sacxovrebeli adgilis an skolis Secvla);

danaklisebi (sayvareli adamianis gardacvaleba, mSoblebis daSoreba);

Zaladoba (seqsualuri an fizikuri, ojaxuri Zaladoba);

travmatizmi (magaliTad sagzao SemTxveva).

ojaxuri istoria

ADHD-s qvetipebi icvleba ara marto Tanmxlebi daavadebebis, aramed aseve ojaxis istoriaze dayrdnobiT. ADHD-s hiperaqtiuri impulsuri qvetipis mqone bavSvebis ojaxebSi ufro metia ADHD-s, agresiisa da wamalTdamokidebulebis SemTxvevebi, maSin roca ADHD-s uyuradRebobis qvetipis mqone bavSvebis ojaxebSi ufro

30

metia SfoTviTi aSlilobebi da swavlasTan dakavSirebuli problemebi64.

sanimuSo kiTxva problemis gamosavlenad: mkurnalobda Tu ara vinme Tqvens ojaxSi (mSoblebi, da-Zmebi da sxva naTesavebi):

SfoTviTi aSlilobis gamo;

depresiuli aSlilobis gamo (maT Soris, bipolaruli aSli-loba);

swavlasTan/yuradRebasTan dakavSirebuli problemebis gamo;

ganviTarebis Seferxebis, gonebrivi CamorCenis an autizmis gao;

wamaldamokidebulebis gamo;

qceviTi problemebis gamo;

sxva fsiqikur janmrTelobasTan dakavSirebuli problemebis gamo.

mzrunvelobis (meTvalyureobis) xarisxi

ganixileT ojaxis unari da resursebi sirTuleebis daZlevaSi, iseve rogorc maTi rwmena da kompetencia bavSvis problemebTan dakavSirebiT. aseve gamoikvlieT mTlianobaSi ojaxze bavSvis simptomebis gavlena.

gamohkiTxeT momvlelebs ojaxSi arsebuli garemos Sesaxeb. kerZod, SeafaseT is problemebi, romlebmac SeiZleba negatiuri zegavlena moaxdinon mSobelTa SesaZleblobaze, Tanmimdevrulad da saTanadod marTon qceva, uzrunvelyon adeqvaturi meurveoba Seafason bavSvis funqcionireba.

am problemebs miekuTvneba:

mSoblebis fsiqiatriuli aSliloba an qimiuri midre-kileba/damokidebuleba;

kulturuli gansxvavebebi;

ganaTlebis an informaciis nakleboba;

dabali inteleqtualuri done;

ojaxuri/sazogadoebis mxardaWeris ararseboba;

fsiqologiuri stresorebi (ix. zemoT), da

bavSvze SezRuduli mzrunveloba.

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sanimuSo kiTxvebi:

rogoria Tqvens ojaxSi Cveulebrivi tipiuri dRe?

grZnobs Tu ara bavSvi skolis da zogadad sazogadoebis mxardaWeras?

vin uwevs daxmarebas Tqvens Svils, rodesac Tqven es gWirdebaT?

xdeba Tu ara alkoholis an dauSvebeli wamlebis (narko-tikebis) moxmareba Tqvens ojaxSi?

SegiZliaT momiyveT ra gsmeniaT an giswavliaT ADHD-s Sesaxeb?

disciplinis ra saxeoba moqmedebs (an ar moqmedebs) Tqvens Svilze?

rodis grZnobT siamovnebas Tqvens bavSvTan yofnisas?

mtkicebuleba C, R klasisaa.

4. metyvelebis/laparakis problemebi

mTavari momentebi:

Tu skriningi mianiSnebs problemebze bavSvis metyvelebasa da/an laparakTan dakavSirebiT, maT Soris eqspresiul da receptul metyvelebas, mwyobr metyvelebas, pragmatul metyvelebas, prosodias (leqsTa SeTxzvas), an fonologia/artikulaciis problemebs, aucilebelia gaigzavnos metyvelebisa da saubris paTologistTan.

Tu saxezea saubris an metyvelebis problemebi, romlebic mogvagonebs fsiqologiuri ganviTarebis zogad aSlilobas, maSin aucilebelia mimarTva ganviTarebis an fsiqikuri janmrTelobis profesionalebTan, diagnostikur jgufSi saubris da metyvelebis specialistis monawileobiT.

ADHD-s mqone bavSvebi imyofebian xmis iogebis “araswori gamoyenebis~ momatebuli riskis qveS. Tu aRmoCnda, rom bavSvs aqvs qronikuli (6 Tve da meti) “Wriala” an xrinwiani xma, maSin rekomendebulia otolaringologTan mimarTva xmis iogebis paTologiis dadgenis mizniT, rogoricaa xmis iogebis gasqeleba an xmis iogebis kvanZebi.

ADHD-s mqone bavSvebSi periodulad ganmeorebadi xmebis, yelis gasufTavebis mcdelobis, qSinvis, xvelis an kopro-laliis (uxamsi sityvebis impulsuri warmoTqma) arseboba migvaniSnebs toretis Tanmxleb sindromze. am dros

32

rekomendebulia konsultacia nevrologTan, ganviTarebis da qceviTi problemebis pediatrTan, an bavSvTa fsiqiatrTan.

ADHD-s mqone bavSvebis 50%-s SeiZleba aRmoaCndes metyvelebis problemebi. verbaluri funqcionirebis problemebi SesaZloa, qronikuli iyos da gansakuTrebiTaa gavrcelebuli antisocialuri qcevis mqone mozardebSi. metyvelebis da saubris Seferxebis farTod gavrcelebuli sirTuleebia:

mwyobri metyvelebis dakargvasTan dakavSirebuli warsuli da axlandeli problemebi;

araorganizebuli metyveleba iseTi amocanebis Sesrulebisas, romlebic moiTxovs verbalur axsnas;

moWarbebuli (zedmeti), zedapiruli an swrafi metyveleba;

problemebi xmis tembris modulaciasTan;

fragmentaruli winadadebebi pauzebiT.

metyvelebis problemebi SeiZleba aseve aRmocendes ADHD-s mqone bavSvebSi an SeiZleba warmoadgendes Tanmxleb daavadebas. aseTma bavSvebma SeiZleba moaxdinon yuradRebasTan dakavSirebuli pirvelxarisxovani mniSvnelobis problemebis imitireba da hqondeT problemebi miTiTebebis midevnebisas da verbalurad warmodgenili masalis damaxsovrebisas65 (C).

ADHD-s mqone bavSvTa umetesoba amJRavnebs `pragmatul sasaubro disfunqcias~ socialur situaciebSi _ kerZod, gamorCeuli verbaluri, araverbaluri da situaciuri miniSnebebis amocnobis uZluroba. aman SeiZleba gamoiwvios socialurad miuRebeli arCevnis gakeTebis tendencia. ADHD-s mqone bavSvebis 50%-ze mets savaraudod aqvT sakomunikacio/saurTierTobo problemebi, rac mJRavndeba rogorc socialuri unarebis deficiti. klinicistma unda gamoikiTxos agresiuli, despoturi da momabezrebeli socialuri urTierTobis stilis, aseve megobrobis inicirebis da SenarCunebis sirTuleebis da Tundac Tanatolebis mxridan pirdapiri miuReblobis faqtebis Sesaxeb.

smenis darRvevebi

smenis darRvevebis mqone bavSvebs aseve SeiZleba hqondeT ADHD, maTi smenasTan dakavSirebuli problemebis garda. Aaman SeiZleba gaarTulos diferencialuri diagnozi da aseT SemTxvevaSi saWiroa specialistebis konsultacia.66(R). smenis darRvevebis mqone bavSvebs SeiZleba aseve gamoumJRavndes uyuradRebobis simptomebi, problemebi amocanis dasrulebasTan dakavSirebiT, cudi, agresiuli qceva, daumorCilebloba (reJimis darRveva), saubris da metyvelebis

33

problemebi an informaciis xSiri ganmeorebis saWiroeba. yvela im bavSvs, romelic mowmdeba ADHD-ze, unda hqonoda Catarebuli smenis skriningi bolo 12 Tvis ganmavlobaSi, Tu smenis daqveiTebaze mainc Cndeba eWvi, saWiroa audiogramis Catareba.

ganviTarebis perversiuli aSliloba (mag. autisturi aSliloba, aspergeris sindromi)

perversiuli aSlilobis maniSnebeli niSnebi saubris/metyvelebis TvalsazrisiT moicavs:

gadaWarbebul TavisTavTan saubars;

uCveulo intonaciur models an monotonurobas;

eqolalias (eqofrazias, sityvebis gauazrebel ganmeorebas);

iseT qmedebas, TiTqos ar esmis;

socialurad arasaTanado qcevas (mag. yvirils, saubarSi Carevas);

manamde SeZenili enobrivi unarebis dakargvas.

Tu arsebobs saubris da metyvelebis problemebi, romlebic migvaniSnebs fsiqologiuri ganviTarebis aSlilobaze, aucilebelia pacientis gagzavna ganviTarebis an fsiqologiuri janmrTelobis profesionalTan, diagnostikur gundSi saubrisa da metyvelebis specialistis CarTva.

ADHD-s mqone pacientebma, romlebsac aqvT Tanmxlebi saxmo iogebis an turetis sindromi SeiZleba gamoamJRavnon saubris iseTi modeli, romelic tipiuria aseTi pacientebisaTvis, maT Soris, periodulad ganmeorebadi xmebi, yelis gasufTavebis mcdelobis, qSinva, xvela da Tundac koprolalia (uxamsi sityvebis impulsuri warmoTqma). SeiZleba mizanSewonili iyos konsultacia nevrologTan, ganviTarebis da qceviTi problemebis pediatrTan an bavSTa fsiqiatrTan.

mtkicebuleba D, R klasisaa.

5. akademiuri moswrebis/swavlasTan dakavSirebuli problemebi

mTavari momentebi:

ADHD-s mqone bavSvebis daaxloebiT 25-30%-s aseve aqvs speci-fikuri akademiuri unarebis deficiti an `swavlebis aTvisebasTan dakavSirebuli aSliloba~ iseT sferoebSi, rogoricaa kiTxva, marTlwera an maTematika.

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dabali inteleqtis mqone bavSvebi SeiZleba Candnen uyuradReboni gaazrebis an masalis srulad aTvisebis naklebobis gamo. aseT bavSvebs ufro xSirad aqvT Tanmxlebi ADHD, vidre sxva bavSvebs.

Tu anamnezi da skriningi migvaniSnebs mniSvnelovan proble-mebze akademiuri funqcionirebisa, bavSvma unda gaiaros individualuri kognitiuri/fsiqoganmanaTlebeli Sefaseba.

ADHD-s mqone bavSvebi arian akademiurad CamorCenis momatebuli riskis qveS da xSirad moixseniebian rogorc dabali moswrebis mqoneebi. istoria unda moicavdes mSoblebisa da maswavleblebisgan miRebul informacias, raTa Sefasebul iqnas ADHD-s mqone bavSvebSi problemuri sferoebi, romlebic moicavs:

damoukidebeli muSaobis droulad dasrulebas;

yuradReba detalebis mimarT;

momzadeba gamocdebisaTvis;

Canawerebis gakeTeba saklaso oTaxSi mosmenili leqciebis Sesaxeb;

saorganizacio unarebi;

drois dagegmva;

sakuTar Tavze dakvirveba.

empiriulad miRebuli mtkicebulebebi migvaniSnebs mdgrad kavSirze ADHD-sa da swavlebis sirTuleebTan dakavSirebul aSlilobas Soris. ADHD-s mqone yoveli sami-oTxi bavSvidan erTs aqvs konkretuli akademiuri moswrebis problema an `swavlebis aTvisebasTan dakavSirebuli aSliloba~, iseT tradiciulad gansazRvrul sferoebSi, rogoricaa kiTxva, marTlwera an maTematika. swavlebis sirTuleebTan dakavSirebuli aSliloba formalurad ganisazRvreba sxva studentTa IQ-s (inteleqtis koeficienti) qulebis SedarebiT mis qulebTan.

swavlebis sirTuleebi an aSliloba amJamad ganisazRvreba DSM-IV-iT da moicavs:

problemebs kiTxvisas;

problemebs maTematikaSi;

problemebs weriTi gamosaxvisa da

ganviTarebasTan dakavSirebul koordinaciis aSlilobas.

dabali inteleqtis mqone bavSvebi SeiZleba Candnen uyuradReboni gaazrebis problemis gamo da im masalis aTvisebisas, romelic

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zedmetad rTulia maTTvis. Tumca, aseve mniSvnelovania imis aRniSvna, rom kognitiuri darRvevebis mqone bavSvebs 3-4 jer ufro xSirad aqvT ADHD, vidre bavSvebs, romelTa inteleqtis maCvenebeli normalur diapazonSia. Sesabamisad, IQ-s Sefaseba da individualuri miRwevebis testireba SeiZleba xSirad iyos ADHD-s Sefasebis aucilebeli Semadgeneli nawili. mniSvnelovania imis aRniSvna, rom aseT bavSvebs SeiZleba araswori diagnozi daesvas rogorc yuradRebasTan dakavSirebuli problemebis mqoneebs, maSin roca sinamdvileSi maTi simptomebi meoradia.

mniSvnelovania saskolo problemebis gadaxedva pacientTan, mSob-lebTan, maswavleblebTan da skolis sxva profesionalebTan erTad. swavlebis sirTuleebi SeiZleba moicavdes moicavdes Semdeg simptomebs:

aSkara apaTias an mtrul ganwyobilebas skolisadmi;

Tavis daRwevas an warumateblobas konkretuli sagnebis sferoSi;

cud (agresiul) an uaryofiT qcevas garkveul klasebSi;

konkretuli unarebis sferoSi arsebuli sirTuleebis dokumentirebul mtkicebulebebs;

SesaZlo kiTxvebis magaliTi, romliTac mimarTaven bavSvebs da maT mSoblebs akademiuri moswrebis im sakiTxebis SefasebisaTvis, romlebic warmodgenilia ADHD-s Sefasebis konteqstSi, SeiZleba moicavdes:

romeli sagania TqvenTvis yvelaze sayvareli/advili?

romeli sagania yvelaze rTuli/naklebad sayvareli?

rogor eguebiT da ra urTierToba gaqvT maswavleblebTan?

ra moculobis saSinao davalebas asrulebT saSualod saRamos saaTebSi? rogor Seefereba es saSinao davaleba im moculobas, romelsac asruleben Tqveni Tanaklaselebi? ramdenad gexmarebian Tqveni mSoblebi saSinao davalebis SesrulebaSi?

ra niSnebs Rebulobs TiToeuli maTgani klasSi? rogor Seefereba es wina wlebSi miRebul niSnebs? hqondaT Tu ara adre warumatebloba an amJamad xom ar gaqvT problemebi swavlebisas?

giweven Tu ara raime specialur daxmarebas skolaSi?

ra interesebi gagaCniaT skolis farglebs gareT?

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aqvs Tu ara Tqvens vaJiSvils/qaliSvils raime problemebi swavlebis/saorganizacio unar- CvevebTan dakavSirebiT?

raSia Tqveni azriT Tqveni vaJiSvilis/qaliSvilis saswavlo stilis siZliere? sisuste?

rogor fiqrobT, ganwyobilia Tu ara Tqveni bavSvi pozitiurad skolis mimarT?

gekontaqtebodaT Tu ara odesme vinme skolidan Tqveni Svilis konkretuli akademiuri moswrebis an qcevis problemebTan dakavSirebiT?

kmayofili xarT Tqveni Svilis niSnebiT?

rogor grZnobT, amJRavnebs Tqveni vaJiSvili/qaliSvili Tavis potencials?

“gansakuTrebuli niWiT dajildoebulma” studentebma kognitiur sferoSi cvlilebebiT, SeiZleba aseve gamoamJRavnon ADHD-s iseTi niSnebi an simptomebi, rogoricaa uyuradReboba, cudi (agresiuli) qceva da saklaso oTaxSi gamarTuli saqmianobaSi CarTulobis aSkara nakleboba. mniSvnelovania imis aRniSvna, rom aseT bavSvebs SeiZleba araswori diagnozi daesvas, rogorc ZiriTadad yuradRebis deficitTan dakavSirebuli problemebis mqoneebs, maSin roca sinamdvileSi maTi simptomebi meoradia. Tumca “gansakuTrebuli niWiT dajildoveba” (niWiereba) da ADHD SeiZleba erTdroulad arsebobdes.

prospeqtuli klinikuri dakvirvebebi ADHD-s mqone bavSvebze mozrdil asakSi migvaniSnebs, rom es populacia imyofeba qroni-kuli warumateblobisa (miuRwevlobis) da skolidan garicxvis momatebuli riskis qveS.

mtkicebulebebi C klasisaa.

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6. mkurnaloba

zogadi rekomendaciebi

ADHD-s medikamenturi mkurnaloba unda dainiSnos mxolod ADHD-ze specializebuli fsiqiatris, nevrologis an pediatris mier;

pirveli rigis mkurnaloba ADHD-is mqone pacientTa umravlesobisaTvis mastimulirebeli medikamentebia (A);

Cveulebriv, adekvaturad monitorirebuli farmakoTerapia metad efeqturia, vidre mxolod intensiuri qceviTi Terapia (B).

skolamdeli asakis bavSvebTan medikamenturi Terapia ar aris rekomendebuli (D);

medikamentur TerapiasTan erTad aucilebelia qceviTi, saganmanaTleblo, fsiqologiuri rCevebi da aqtivobebi, medikameturi da kognitur-qceviTi Terapiis kombinacia ufro efeqturia, vidre nebismieri maTgani cal-calke (A) 67;

medikamenturi mkurnalobis dawyebamde unda Catardes ekg im pacientebTan, romelTac gasinjvisas aRmoaCndaT raime paTologiuri cvlilebebi gul-sisxlZarRvTa sistemis mxriv, an aReniSnebaT anamnezSi gulis daavadeba, an aqvT gulis seriozuli daavadebis, an axalgazrda asakSi uecari sikvdilis ojaxuri anamnezi.

farmakologiuri mkurnaloba

mniSvnelovania gaviTvaliswinoT, rom ADHD-s medikamenturi mkurnalobis daniSvna, iseve, rogorc mkurnalobis sqemis Secvla an gadawyvetilebis miReba mkurnalobis Sewyvetis Sesaxeb unda moxdes specializebuli fsiqiatris, nevrologis an pediatris mier.

pirveli rigis medikamenturi Terapia ADHD-s SemTxvevaSi stimulantebia 68 . ormagi brma, placebo-kontrolirebadi kvlevis mixedviT, klinikuri gaumjobeseba aReniSnaT ADHD-s mqone pacientTa 60-75%-s stimulantebis jgufidan xolo sakontrolo jgufidan – 4-30%-s 69 . arCevani Tavisufalia stimulantebis 2 tipis medikamentebs Soris – amfetaminis warmoebulebsa da metilfenidinis warmoebulebs Soris da maTi efeqturoba Tanabaria 70 . kvlevebis mixedviT, am medikamentTa gaxangrZlivebuli formebi iseve efeqturi ADHD-s samkurnalod bavSvebSi da mozrdilebSi, rogorc xanmokle formebi 71 , (B). atomoqsetini,

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noradrenerguli ukumitacebis seleqtiuri inhibitori, meore rigis medikamentia da misi efeqturoba dadasturebulia randomizebuli, placebo-kontrolirebadi kvlevebiT 72 , 73 . sxva medikamentebis efeqturobaze, rogorica buproprioni, tricikluri antidepresantebi da alfa2-agonistebi, mtkicebulebebi naklebadaa74.

mkurnaloba iwyeba dabali dozebiT da Semdeg xdeba dozis titracia, rodesac pirveli rigis erTi medikamenti ar aris efeqturi, jer unda icados aseve pirveli rigis meore medikamenti da uefeqtobis SemTxvevaSi moxdes gadasvla meore rigis medikamentze. SesaZlebelia medikamentis daniSvna gansxvavebuli reJimebiT: mudmivi miReba an uqmeebze medikamentebisagan ”dasveneba”. uqme dReebSi medikamentebisagan dasvenebis reJimi rekomendebulia im bavSvebisaTvis, romelTac ADHD-s simptomebi ufro metad saskolo saqmiaobaSi CamorCenis ganviTarebas ganapirobebs, an mkurnalobis gverdiTi efeqtebis Semcirebaa aucilebeli. gverdiTi efeqtebis Semcireba aseve SesaZlebelia medikamentis sakvebTan erTad miRebiT an dozis SemcirebiT.

atomoqsetinis daniSvna unda moxdes im SemTxvevaSi, rodesac stimulantebi araefeqturia, an mSoblebi arian stimulantebis miRebis winaaRmdeg, an, rodesac savaraudoa pacientis, an ojaxis wevrebis mier medikamentze damokidebuleba.

qceviTi Terapia

sworad warmaTuli kognitur-qceviTi Terapia medikamentur TerapiasTan erTad saWiroebis SemTxvevaSi sakmaod efeqturia, mniSvnelovania ojaxisa da momvlelis ganaTleba, mxardamWeri jgufebis Seqmna, sadac ADHD-s diagnozis mqone bavSvis mSoblebi erTmaneTs gauziareben TavianT gamocdilebas, sakmaod efeqturi da gamocdili meTodia waxaliseba, magaliTad yvela karg saqcielze an kargad Sesrulebul davalebaze prizis an qulis miniWeba75.

qceviTi Terapia 3 mimarTulebiT unda warmoebdes:

1. mSoblebze fokusirebuli strategia,

2. bavSvze fokursirebuli strategia

3. skolis personalze fokusirebuli strategia.

mSoblebze fokusirebuli strategia

mSoblebs unikaluri roli aqvT ADHD-s marTvaSi, maT aqvT SesaZlebloba iyvnen Tavisi bavSvis gverdze sxvadasxva garemoSi da arian mkveTrad motivirebulni, raTa gaakeTon maqsimumi Tavisi Svilis warmatebuli momavlisaTvis. maTi survilia ixilon Svilis warmateba ara marto swavlaSi, aramed yvela garemoSi – sportSi,

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amxanagebTan da a.S.. mxolod isini imyofebian bavSvis gverdiT xangrZlivi drois manZilze da maTi mizania, bavSvi gaxdes sazogadoebis srulfasovani da kargad adaptirebuli wevri.

mSoblebi, romelTac gavlili aqvT specialuri treiningebi, yvelaze ukeT axerxeben moagvaron qceviTi problemebi, romlebic aReniSnebaT bavSvebs ADHD-Ti76 (R).

rCevebi mSoblebisaTvis:

aRwereT bavSvis problemuri qceva (werilobiT), misi sixSire da simZafre, raTa gaadvildes monitorireba da dinamikis Sefaseba;

gamoyaviT 10-15 wuTi dReSi mxolod bavSvisaTvis, mousmineT mas, agrZnobineT, rom igi TqvenTvis Zalian mniSvnelovania;

SeimuSaveT mkacri grafiki da rutinuli qcevebi, grafikidan gadaxveva unda moxdes ukiduresad iSviaTad;

daaweseT simboluri prizi yoveli kargi saqcielisaTvis, dRis an kviris bolos daajameT prizebi bavSvis TandaswrebiT;

erTdroulad gaaxmovaneT msolod 1 an 2 martivi, mkafiod Camoyalibebuli instruqcia, gaameorebineT bavSvs es instruqcia, raTa darwmundaT, rom man kargad gaigo;

ojaxis sxva wevrebisTvisac unda iyos qcevis wesebisa da rutinebis nusxa, rom maTi qceva SesabamisobaSi iyos bavSvis reJimTan;

SeamcireT araadekvaturi qceva Semdegi meTodebiT: gaaanalizeT qceva bavSvTan erTad; logikurad auxseniT bavSvs qcevis araswori

buneba; aiReT “taim-autebi”, Tu TvliT, rom bavSvs Zalian uWirs

reJimis dacva an avlens agresias;

SeimuSaveT Zilis mkafio Cveva, uzrunvelyaviT mSvidi garemo bavSvis saZinebelSi;

gamoyaviT mosaxerxebeli, izolirebuli oTaxi/kuTxe saSinao davalebis Sesasruleblad;

mieciT bavSvs arCevnis gakeTebis ufleba, magram SeTavazebebis variantebi unda iyos SezRuduli da bavSvs hqondes kontrolis arsebobis grZnoba;

kargad auxseniT bavSvs, rom problemas warmoadgens misi qceva da ara TviTon bavSvi;

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bavSvze fokurirebuli strategia

mniSvnelovania bavSvma iswavlos qcevisa da emociebis marTva, treiningis umTavresi mizania, bavSvi ADHD-Ti mieCios “gaCerebas da dafiqrebas” moqmedebamde.

skolaze fokusirebuli strategia

swavlis Cvevebis gaumjobeseba

saswavlo masala (davaleba) unda daiyos samuSao da samarTav nawilebad, momdevno punqtze gadasvla unda moxdes mxolod davalebis wina nawilis dasrulebis Semdeg;

saklaso oTaxi unda iyos organizebuli, qcevis mkafio wesebiT;

bavSvis oTaxSi an samecadino kuTxeSi gamokruli unda iyos dRis ganrigi, saSinao davalebebis micema unda moxdes werilobiTi saxiT, bavSvi unda ijdes maswavlebelTan axlos da mis gverdiT sasurvelia ijdes pozitiuri magaliTi – bavSvi kargi qceviTi CvevebiT;

unda daeTmos dro swavlis Cvevebisa da drois marTvis swavlebas;

sasurvelia xSiri, gegmiuri Sesvenebebi;

dauyovneblivi pozitiuri ukukavSiri kargi qcevis SemTxvevebSi;

maswavlebelsa da mSobels Soris informaciis sistematiuri gacvla, rac SesaZlebelia specialuri yoveldRiuri baraTebis sistemis SemoRebiT;

moswavlesTan TviTSefasebaze da TviTkontrolis Cvevevze muSaoba, kompensatorul/adaptaciuri strategiebis SemuSaveba;

dakvirveba medikamenturi Terapiis gverdiT efeqtebze

zogadi rekomendaciebi

rutinuli sisxlis analizi an ekg ar aris rekomendebuli Tu ar aRiniSneba Sesabamisi Cveneba;

RviZlis dazianeba atomoqsetinis iSviaTi da idiosinkraziuli gverdiTi efeqtia – RviZlis funqciebis rutinuli analizi ar aris rekomendebuli. mSobeli an momvleli unda gafrTxeldes aRniSnuli gverdiTi moqmedebis Sesaxeb (Cveulebriv gamovlindeba muclis tkiviliT, auxsneli gulisreviTa da RebinebiT, Sardis gamuqebiTa da siyviTliT);

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qvemoTaRniSnuli monitorireba unda warmoebdes meTilfenidatis, atomoqsetinisa da deqsamfetaminis miRebis SemTxvevaSi, Tu sxvagvarad ar aris miTiTebuli.

simaRle (unda gakontroldes bavSvebi da mozardebi)

unda gaizomos yovel 6 TveSi, zrdis mrudi unda Seafasos eqimma, romelic iRebs gadawyvetilebas mkurnalobis Sesaxeb;

Tu aRiniSneba mniSvnelovani CamorCena simaRleSi, unda moxdes medikamenturi Terapiis Sewyveta ardadegebze, raTa moxdes CamorCenis anazRaureba.

wona (unda gakontroldes bavSvebi, mozardebi da mozrdilebi)

unda giazomos me-3 da me-6 Tveze mkurnalobis dawyebidan da Semdeg yovel 6 TveSi. bavSvebisa da mozardebis SemTxvevaSi unda Sedges zrdis Carti da Sefasdes mkurnali eqimis mier;

Tu mozrdilebTan wonis kleba asocirebulia medikamentur TerapiasTan, unda gakontroldes sxeuli masis indeqsi da gadawydes medikamenturi Terapiis Sewyveta wonis persistuli klebis SemTxvevaSi;

bavSvebTan wonis regulaciisaTvis Semdegi gzebia mowodebuli:

o medikamentis miReba unda moxdes Wamis dros an Wamis Semdeg nacvlad Wamamde miRebisa;

o pacientma unda miiRos damatebiTi sakvebis ulufa diliT adre an gvian saRamos, rodesac stimulantis moqmedeba minimaluria;

o sakvebi racioni unda iyos maRalklaoriuli, srulfasovani.

gulis funqciebi da arteriuli wneva (unda gakontroldes bavSvebi, mozardebi da mozrdilebi)

gulis riTmi da arteriuli wneva unda gakontroldes yvela dozis cvlilebisas da 3 TveSi erTxel da dafiqsirdes centilur CartSi,

taqikardia mosvenebis dros, ariTmia, da sistoluri wneva 2 jer gazonili 95 percentilze meti (an klinikurad mniSvnelobani mateba) unda gaxdes eqimTan mimarTvisa da dozis Semcirebis signali.

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reproduqciuli sistema da seqsualuri funqcia (unda gakontroldes mozardebi da mozrdilebi, mxolod atomoqsetinis miRebis SemTxvevaSi)

unda moxdes dismenoreis, ereqciuli da eakulaciuri disfunqciis monitorireba;

gulyrebi (bavSvebi, mozardebi da mozrdelebi – meTilfenidatisa da atomoqsetinis miRebis SemTxvevaSi)

Tu aRineniSnebaT gamwvaveba bavSvebs, romelTac hqondaT epilefsia, an fiqsirdeba axladaRmocenebuli gulyrebi, medikamenti unda Sewydes dauyovnebliv;

mesameuli donis specialistTan SeTanxmebiT unda iqnes ganxiluli deqsamfetaminis daniSvnis sakiTxi.

tikebi (bavSvebi, mozardebi da mozrdilebi – meTilfenidatisa da deqsamfetaminis miRebis SemTxvevaSi)

ganixileT, aris Tu ara tiki stimulantiT gamowveluli, da aris Tu ara tikebiT gamowveluli ziani metad mniSvnelovani, vidre ADHD-s mkurnaloba;

Tu tikebi stimulantebiTaa gamowveuli, ganixileT daniSnuli stimulantis atomoqsetiniT Secvla

fsiqotikuri simptomebi (bodva, halucinacia) (bavSvebi, mozardebi da mozrdelebi – meTilfenidatisa da deqsamfetaminis miRebis SemTxvevaSi)

unda Sewydes medikamenturi mkurnaloba, Catardes sruli fsiqiatriuli gamokvleva;

ganixileT atomoqsetinis daniSvnis sakiTxi

SfoTvis simptomebi panikis CaTvliT (bavSvebi, mozardebi da mozrdelebi – meTilfenidatisa da deqsamfetaminis miRebis SemTxvevaSi)

rodesac simptomebi gamowveulia stimulantebiT, gansakuTrebiT mozrdilebSi, romelTac aReniSnebaT Tanmxlebi SfoTviTi aSliloba, Semcirebuli unda iqnes doza da/an kombinirebuli Terapia warimarTos antidepresantTan erTad, romelic gamoiyeneba SfoTviTi aSlilobisas;

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SesaZloa, efeqturi iyos atomoqsetinze gadasvla.

aJitacia, gaRizianebadoba, TviTmkvllobaze fiqri, TviTdaSaveba – (atomoqsetinis miRebis SemTxvevaSi)

mWidro monitorireba, gansakuTrebiT mkurnalobis dawyebis pirvel Tves an dozis momatebis Semdeg;

atomoqsetinis daniSvnis SemTxvevaSi pacienti an mSobeli/momvleli unda gafrxilebul iqnes, rom preparatis erT-erTi gverdiTi movlenaa suicidaluri azrebi, TviTdaSaveba, rac gansakuTrebiT xSiria mkurnalobis pirveli kvirebis ganmavlobaSi. nebismieri gamovlenisas aucilebelia eqimis saqmis kursSi Cayeneba;

7. reabilitacia / meTvalyureoba

meTvalyureoba

aucilebelia daavadebuli bavSvis monitoringi. mSoblebisgan, maswavleblebisgan da uSualod bavSvisgan miiReba dawvrilebiTi informacia samizne Sedegebisa da gverdiTi efeqtebis Sesaxeb. monitoringis sixSire damokidebulia disfunqciis doneze, gar-Tulebebze, daniSnuli mkurnalobis xasiaTze. bavSvis mdgomareobis stabilizaciis Semdeg eqimTan 3-6 TveSi erTxel mosvlac sakmarisia.

mizandasaxuli mkurnalobis Sedegad, klinikuri niSnebis gamoxatuleba asakis matebasTan erTad klebulobs. miuxedavad amisa, mozardebis 22-85%-sa da mozrdilebis 4-66%-Si diagnozis moxsna ver xerxdeba77,78

daskvna

amrigad, yuradRebis deficitis/hiperaqtivobis sindromi warmoadgens saskolo asakis bavSvebSi qronikulad mimdinare daavadebas, romelic mniSvnelovan zegavlenas axdens socialur adaptaciasa da akademiur moswrebaze. mkurnalobis gareSe simptomebi xSirad mozrdilobis asakSic grZeldeba. mkurnaloba moicavs medikamentur da qceviT Terapias. efeqtis miRebisaTvis mizanSewonilia samizne Sedegebis moxazva da mkurnalobis dagegm-vaSi uSualod bavSvis CarTva. aucilebelia pacientis mdgomareobis mudmivi monitorireba.

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8. eTikur-samarTlebrivi sakiTxebi

yuradRebis deficitis hiperaqtivobis sindromis marTva da mkurnaloba pirveladi jandacvis sistemaSi samedicino eTikis mTavari principebis dacviT unda ganxorcieldes. arsebiTi mniSvneloba pacientis uflebebis dacvis da gadawyvetilebis miRebis procesSi mis monawileobas aqvs. bavSvTa asakSi diagnostirebuli ADHD-s SemTxvevaSi mSoblebs unda miewodoT sruli informacia daavadebis mimdinareobis, qceviTi Terapiis, medikamenturi mkurnalobis efeqturobisa da gverdiTi movlenebis Sesaxeb da isini intensiurad unda iyvnen CarTulni mkurnalobis procesSi. gansakuTrebiT didi sifrTxiliT unda moxdes diagnozis dasma, raTa arasworad dasmulma diagnozma uaryofiTi gavlena ar moaxdinos bavSvis momavalze, meores mxriv, gasaTvaliswinebelia, rom droulad dawyebuli mkurnaloba exmareba bavSvs da mozards, marTon yoveldRiuri yofiTi Cvevebi.

aseve, sayuradReboa is faqtic, rom stimulantebiT mkurnalobis dros SesaZlebelia wamlis aramiznobrivad miReba pacientis, an ojaxis wevrebis, an megobrebis mier. amis gamo mSoblebisa da skolis pedagogebis/aRmzrdelebis CarTulobas mkurnalobis monitorirebis procesSi didi yuradReba unda daeTmos.

9. praqtikaSi adaptaciis da protokolis SemuSavebis

rekomendaciebi

klinikuri praqtikis auditis kriteriumebi

auditis kriteriumebi dafuZnebulia gaidlainis rekomendaciebze yuradRebis deficitis/hiperaqtivobis sindromis mqone pacientebTan mimarTebaSi. mocemuli standartebi rogorc wesi an 100%, an 0%. Tu isini ar aris miRwevadi mokle drois ganmavlobaSi, ufro Sesaferisi standarti unda dadgindes, adgilobriv klinicistebTan diskusiebis safuZvelze. Tumca, mocemuli standartebi saboloo miznad unda darCes.

yuradRebis deficitis/ hiperaqtivobis sindromis auditis kriteriumebi:

1. pacientTa procentuli raodenoba, visac daudginda yuradRebis deficitis/ hiperaqtivobis sindromi da dafiqsirda samedicino CanawerebSi (baraTSi) bolo 12 Tvis ganmavlobaSi.

45

2. axalgazrda da mozrdilTa pacientTa procentuli raodenoba, visac bavSvTa asakidanve daudgindaT yuradRebis deficitis/ hiperaqtivobis sindromi da gaTviTcnobierebuli aqvT informacia sakuTari mdgomareobis Sesaxeb, bolo 12 Tvis ganmavlobaSi.

3. pacientTa procentuli raodenoba, romelTac aReniSnebaT yuradRebis deficitis/ hiperaqtivobis sindromis diagnostikuri kriteriumebis simptomebi: yuradRebis deficiti, hiperaqtivoba, an impulsuroba.

4. pacientTa procentuli raodenoba, romelTac CautardaT fsiqologiuri, socialuri samsaxurebis daxmareba bolo 12 Tvis ganmavlobaSi.

samizne mosaxleoba (pacientTa jgufebi).

Sesabamis pacientTa jgufebs warmoadgenen yuradRebis deficitis/hiperaqtivobis sindromis mqone bavSvebi, mozrdilebi da axalgazrdebi.

monacemTa wyaroebi

auditis kriteriumebi SeiZleba moiTxovdes monacenebis Segrovebas sxvadasxva wyarodan, maT Soris saprogramo dokumentebidan da pacientTa Sesaxeb arsebuli Canawerebidan.

xelaxali auditi (re-auditi)

miuxedavad imisa, emTxveva Tu ara pacientis Sesaxeb miRebuli Sedegebi standartebs, xelaxali auditi warmoadgens auditis ciklis mniSvnelovan nawils. Tu pirveladi monacemebis Segroveba da analizi gviCvenebs gaumjobesebis SesaZleblobas, maSin unda SemuSavdes Semdgomi moqmedebaTa gegma. momsaxurebaSi xelaxali auditis erTjerad cvlilebebs unda mieces dro, raTa maT gavlena moaxdinon procesze. gamomdinare cvlilebebis bunebisagan amas SeiZleba ramodenime kvira an Tve dasWirdes. procesi unda gagrZeldes manam, sanam auditis Sedegebi ar mova SesabamisobaSi standartebTan. savaraudo drois periodia konsultaciebi 12 Tvis ganmavlobaSi.

10. gaidlainis miRebis xerxi/wyaro

gaidlaini warmoadgens sxvadasxva gaidlainebis (ix. literatura) Sejerebis da adaptaciis Sedegs.

46

11. alternatiuli gaidlaini

alternatiuli gaidlaini ar arsebobs.

12. mtkicebulebis done, rekomendaciebis xarisxi

klasi mtkicebuleba

A swori dizainis mqone randomizebuli kontrolirebadi kvleva

B kohortuli kvleva

C klinikuri kvleva randomizaciis gareSe, kohortuli da SemTxveva-

kontrolis kvlevebi

D

araeqsperimentuli multicentruli kvlevebi

jvaredini kvleva

SemTxvevaTa seria

SemTxvevaTa analizi

M meta-analizi

sistemuri mimoxilva

R

klinikuri gamocdileba,

eqspertTa angariSi,

eqspertTa konsensusi

X avtoritetul profesionalTa mosazreba

47

13. gamoyenebuli literatura

“Attention Deficit Hyperactivity Disorder (ADHD) “ The nice Guideline on Diognosis

and Management of ADHD in children, Young People and Adults, National

Collaborating centre for Mental Health. The British Psychological society & The Royal

College of Psychiatrists, 2009.

“Diagnosis And Management of Attention Deficit Hyperactivity Disorder in Primery

Care for School- Age Children and Adolescents.” Seventh Edition March 2007. By

institute for Clinical systems Improvement. www. icsi. Org

“ Attention Deficit Hyperactivity Disorder.” From Wikipedia, the free encyclopedia. 6,

august, 2009.

“Current Strategies in the Diagnosis and Treatment of Childhood Attention-

Deficit/Hyperactivity Disorder”; ROBERT RADER, MD, DPh, and LARRY

MCCAULEY, EdD, Saint Anthony Family Medicine Residency, Oklahoma City,

Oklahoma, ERIN C. CALLEN, PharmD, Southwestern Oklahoma State University

College of Pharmacy, Weatherford, Oklahoma. Am Fam Physician. 2009;79(8):657-665.

bavSvis fsiqikuri ganviTarebis darRvevebi. Tamar gagoSiZe.

Tbilisi, 2007w.

1 “ NINDS Attention Deficit- Hyperactivity Disorder Information Page. National Institute

of Neurological Disorders and Stroke ( NINDS/ NIH ) February9, 2007. Retrieved on

2007- 08-13. 2 ZwiM, RamchandaniP, JoughinC( October 2000)” evidence and belief in ADHD”.

BMJ( Clinical research ed.) 321( 7267). http:// www.bmj.com/cgi/content/ full/ 321/7267/

975 . 3 American Psychiatric Association. Diagnostic and statistical manual of mantal

disorders(4th

ed. text revision). Washington, DC: 4

Stern HP, Sten TP(September 2002) “ When children with attention- deficit-

hyperactivity disorder become adults.” South. Med J. 95. 5 Barkley, Russell A. (2007) “ A DHD in Adults: History, Diagnosis and Impairments.”

http:// www. continuingedcourses.net/ active/ courses/ course034.php. Ratrieved on July

27. 2009. 6 Dulcan M( October 1997) “ Practic parameters for the assessment and treatment of

children, adolescents and adults with attention- deficit/ hyperactivity disorder. American

Academy of Child and Adolescent Psychiatry.”J .Am Acad Child Adolesc Psychiatry36. 7 Sing I ( December 2008) “ Beyond polemics: science and athics of ADHD.” Nat. Rav.

Neurosci.9 8 Sciutto M. J. Nolfi, C. J. & Bluhm,C. (2004). Effects of Child Gender and Symptom

Type on Referrals for ADHD by Elementary School Teachers. Journal of Emotional and

Behavioral Disorders. 12. 9 “Attention – Deficit / Hyparactivity disorder (ADHD) : Nature, Course, Outcomes,

and Comorbity.”Barkley, Russell. Retrieved on 2008.

48

10

“Brain Matures A Few Years Late In ADHD, But Foiiows Normal Pattern.”

Sciencedaily.com.2007. Retrieved on 2009. 11

“ LONI: Laboratory of Neuro Imaging.” http:// www. loni. ucla. edu/ Resaerch/

Projects/ ADHD. Shtml# Current Rasearch. Retfieved on 2008 12

Wiener, JerryM, Editor(2003). Textbook Of Child & Adolescent Psychiatry.

Washington, DC: American Psychiatric Association. ISBN. 13

American Academy of Child Adolescent Psychiatry.” ADHD-A Guide for Families.”

June 27, 2009. 14

Tom, CatherineM, Assistant Professor of Pharmecy Practice Arnold & Marie

Schwartz College of Paracy and Health Sciences Long Island University Brooklyn, new

Yirk Clinical Parmecy Manager, PediatricsChildren,s Hospital at Montefiore Bronx,

New York(2005). Recognizing and Treating ADHD in Adolescents and Adults.

Uspharmacist. Com. 15

. Gentile, Julie, Atiq, Rafay Gillig, Paulette. Adult. ADHD: Diagnosis, Differential

Diagnosis and Medication Management.#.Psychiatrymmc. com. 16

Ford, T., Goodman, R. & Meltzer, H. (2003) The British Child and Adolescent Mental

Health Survey 1999: the prevalence of DSM-IV disorders. Journal of the

American Academy of Child and Adolescent Psychiatry, 42, 1203–1211. 17

Cuffe, S. P., Moore, C. G. & McKeown, R. E. (2005) Prevalence and correlates of

ADHD symptoms in the national health interview survey. Journal of Attention

Disorders, 9, 392–401. 18

Polanczyk, G., Silva de Lima, M., Horta, B. H., et al. (2007) The worldwide

prevalence of ADHD: a systematic review and metaregression analysis. American

Journal of Psychiatry, 164, 942–948. 19

Faraone, S. V., Biederman, J. & Mick, E. (2006) The age-dependent decline of

attention deficit hyperactivity disorder: a meta-analysis of follow-up studies.

Psychological Medicine, 36, 159–165. 20

Faraone, S. V. & Biederman, J. (2005) What is the prevalence of adult ADHD?

Results of a population screen of 966 adults. Journal of Attention Disorders, 9,

384–391. 21

Molina BS, Hinshaw SP, Swanson JM, et al. (March 2009). “ MTA at 8 Years:

Prospective Follow- up of Children Treated for Combined – Type ADHD in a Multisite

Study.” J Am Acad Child Adolesc Psychiatry48. 22

http:// web.archive. org/ web/ 20070621111922/ http: // eric. ed.gov/ ERICDocs/ date/

erICDocs2/ content_ storage_ 01/ 0000000b/ 80/ 22/ 94/ d6.pdf PDf(562KB). 23

College Degree Nearly Doubles Annual Earnings, Census Bureau Reports U. S.

Census Bureau March 28,2005. Retrieved on 2008. 24

Smucker WD, Hedayat M (September 2001.) “ Evuluation and treatment of ADHD.”

Am Fam Prysician 64. 25

. “ What is the evidence for using CNS stimulants to treat ADHD in children ?

Therapeutics Initiative.” http:// www. ti. Ubc.ca/ letter69. 26

Jansan PS, Arnold LE, Swanson JM, et al (August 2007) “ 3 year-up of the NIMH

MTA stydy.” J Am Acad Adolesc Psychiatry46. 27

Faraone, S. V. (2005) The scientific foundation for understanding attentiondeficit/

hyperactivity disorder as a valid psychiatric disorder. European Child

49

and Adolescent Psychiatry, 14, 1–10. 28

Roman T, Rohde LA, Hutz MH. (2004). “Polymorphisms of the dopamine transporter

gene: influence on response to methylphenidate in attention deficit- hyperactivity

disorder.” American journal of Pharmacogrnomics4 29

Swanson JM, FlodmanP, Kennedy J, et. Al. “Dopamine Genes and ADHD.” Neurosci

Biobehav rev.2000.Jan 24. 30

Smith KM, Daly M, Fischer M, et.al. “ Assocition of dopamine beta hydroxylase gene

with attention deficit hyperactivity disorder: genetic analysis of the Milwaukee

longitudinal study. Am J Med Genet B Neuropschiatr Genet. 2003 May15. 31

M.T. Acosta, M.Arcos- Burgos, M Muenke(2004) .” Attention deficit hyperactivity

disorder : Complx phenotype, simple genotype?” Genetics in Medicine6. 32

Levy et. al. 1997. Nigg.2006 Sherman, Silberg et al. 1996. 33

Sherman DK, Iacono WG, McGue MK (June1997). “ Attention deficit hyperactivity

disorder dimensions: A twin study of inattention and impulsivity – hyperactivity.” J Am

Acad Child Adolesc Psychiatry36. 34

Linnet, K. M., Dalsgaard, S., Obel, C., et al. (2003) Maternal lifestyle factors in

pregnancy risk of attention deficit hyperactivity disorder and associated behaviors:

review of the current evidence. American Journal of Psychiatry, 160,

1028–1040. 35

Mick, E., Biederman, J., Faraone, S. V., et al. (2002) Case-control study of attention

deficit hyperactivity disorder and maternal smoking, alcohol use and drug use during

pregnancy. American Journal of Child and Adolescent Psychiatry, 41, 378–385. 36

Ornoy, A., Segal, J., Bar-Hamburger, R., et al. (2001) Developmental outcome of

school-age children born to mothers with heroin dependency: importance of

environmental factors. Developmental Medicine and Child Neurology, 43, 668–675. 37

Botting, N., Powls, A., Cooke, R. W. I., et al. (1997) Attention deficit hyperactivity

disorders and other psychiatric outcomes in very low birth weight children at 12 years.

The Journal of Child Psychology and Psychiatry, 38, 931–941. 38

Toren, P., Eldar, S., Sela, B. A., et al. (1996) Zinc deficiency in attention deficit

hyperactivity disorder. Biological Psychiatry, 40, 1308–1310. 39

Keenan HT, Hall GC . Marshall SW(2008) “ Early head injury and attention deficit

hyperacivity disorder : retrospective cohoet study; BMJ 337. 40

“ Mental Health: A report of the surgeon general. 1999. http: // www. surgeogeneral.

gov / library / mantal health/ chapter3/ sec 4. html. Retrieved on 2008. 41

Mautner, V. F., Kluwe, L., Thakker, S. D., et al. (2002) Treatment of ADHD in

neurofibromatosis type I. Developmental Medicine and Child Neurology, 44, 164–170. 42

Hagerman, R. J. (1999) Psychopharmacological interventions in fragile x syndrome,

fetal alcohol syndrome, Prader-Willi syndrome, Angelman syndrome, Smith-

Magenis syndrome, and velocardiofacial syndrome. Mental Retardation and

Developmental Disabilities Research Reviews, 5, 305–313. 43

Gerring, J. P., Brady, K. D., Chen, A., et al. (1998) Premorbid prevalence of ADHD

and development of secondary ADHD after closed head injury. Journal of the

American Academy of Child and Adolescent Psychiatry, 37, 647–654. 44

McCann, D., Barrett, A., Cooper, A., et al. (2007) Food additives and hyperactive

behaviour in 3-year-old and 8/9-year-old children in the community: a

50

randomised, double-blind, placebo-controlled trial. The Lancet, 3, 1560–1567. 45

Adam James (2004) Clinical psychology publishes critiqueof ADHD diagnosis and use

of medication on Children published on Psychminded. Co. uk Psychminded Ltd. 46

Biederman, J., Milberger, S., Faraone, S. V., et al. (1995) Family-environment risk

factors for attention-deficit hyperactivity disorder: a test of Rutter’s indicators of

adversity. Archives of General Psychiatry, 52, 464–470. 47

Schachar, R. J., Tannock, R., Cunningham, C., et al. (1997) Behavioral, situational and

temporal effects of treatment of ADHD with methylphenidate. Journal of the American

Academy of Child and Adolescent Psychiatry, 36, 754–763. 48

“Attention Deficit Hyperactivity Disorder is a neurologically based disorder.”In

crediblehorizons. com. 49

“ Evaluation and diagnosis of attention deficit hyperactivity disorder in children.”

December 5, 2007. 50

Krain, Amy: Castellanos, Xavier (2006). “Brain development and ADHD. “ Cilnical

Psychology Review26. 51

MerckMedicus Modules: ADHD – Pathophysiology. 52

Brain Matures a Few Years Late in ADHD, But Follows Normal Patten NIMH Press

Release, November 12, 2007. 53

Gene Predicts Better Outcome as Cortex Normalizes in Tens with ADHD NIMH Press

Release, August 6, 2007. 54

Lou HC, Andresen J, Steinberg B, McLaughlin T, Friberg L, “ The striatum in

putative cerebral network activated by verbal awareness in normals and in ADHD

children.” EurJ Neurol. 1998. Jan: 5. 55

Dougherty DD, Bonab AA, Spencer TJ, Rauch SL, MadrasBK, Fischeman AJ, (1999).

“ Dopamine transporter denisity in patients with attention deficit hyperactivity disorder

.” Lancet 354. 56

Dresel SH, Kung MP, Ploss K, Meegalla SK, Kung HF, (1998). “ Pharmacologicai

affects of Dopaminergic drugs on in vivo binding of TRODAT-1 to the central dopamine

transporters in rats.” Europen journal of nuclear medicine25. 57

Taylor, E. & Sonuga-Barke, E. (2008) Disorders of attention and activity. In Rutter’s

Child and Adolescent Psychiatry (5th edn) (eds M. Rutter, E. Taylor, J. S.

Stevenson, et al.). London: Blackwell. 58

Clinical practice guideline: diagnosis and evaluation of the child with attention-

deficit/hyperactivity disorder. American Academy of Pediatrics. Pediatrics.

2000;105(5):1158-1170. 59

Dulcan M. Practice parameters for the assessment and treatment of children,

adolescents, and adults with attention-deficit/hyperactivity disorder. American Academy

of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1997;36(10

suppl):85S-121S. 60

Kelly DP, Aylward GP. Attention deficits in school-aged children and adolescents:

current issues and practice. Pediatr Clin North Am 1992;39:487-512. (Class R) 61

O'Brien LM, Holbrook CR, Mervis CB, et al. Sleep and neurobehavioral

characteristics of 5- to 7-yearold children with parentally reported symptoms of

attention-deficit/hyperactivity disorder. Pediatrics 2003;111:554-63. (Class C) 62

Biederman, J., Faraone, S., Milberger, S., et al. (1996) A prospective 4-year followup

51

study of attention-deficit hyperactivity and related disorders. Archives of

General Psychiatry, 53, 437–446. 63

Jensen PS, Shervette RE, Xenakis SN, et al. Anxiety and depressive disorders in

attention deficit

disorder with hyperactivity: new findings. Am J Psychiatry 1993;150:1203-1209. (Class

C) 64

Biederman, J., Faraone, S. V., Keenan, K., et al. (1992) Further evidence for

familygenetic

risk factors in attention deficit hyperactivity disorder: patterns of

comorbidity in probands and relatives psychiatrically and pediatrically referred

samples. Archives of General Psychiatry, 49, 728–738. 65

Cantwell DP, Baker L. Mattison R. prevalence, type and corelate of phsichiatric

diagnosis in 200 children with communication disorder. Dev Behav Pediatr 1981; 2-

131-36 66

Kelly D, Forney J, Parker-Fisher S, et al. Evaluating and managing attention deficit

disorder in children who are deaf or hard of hearing. Am Ann Deaf 1993;138:349-57.

(Class R) 67

A 14-month randomized clinical trial of treatment strategies for attention-

deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study

of Children with ADHD. Arch Gen Psychiatry. 1999;56(12):1073-1086. 68

Rappley MD. Clinical practice. Attention deficit-hyperactivity disorder. N Engl J Med.

2005;352(2):165-173. 69

Greenhill LL (2002), Stimulant medication treatment of children with attention deficit

hyperactivity disorder. In: Attention Deficit Hyperactivity Disorder: State Of Science.

Best Practices, Jensen PS, Cooper JR, eds.Kingston, NJ: Civic Research Institute, pp9-

1Y9-27 70

Goldman LS, Genel M, Bezman RJ, Slanetz PJ. Diagnosis and treatment of attention-

deficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs,

American Medical Association. JAMA. 1998;279(14):1100-1107. 71

Spencer TJ, Abikoff HB, Connor DF et al. (2006), Efficacy and safety of mixed

amphetamine salts extended release Adderall XR in the management of oppositional

defiant disorder with or without comorbid attention-deficit/hyperactivity disorder in

school-aged children and adolescents: a 4-week, multicenter, randomized, double-blind,

parallelgroup, placebo-controlled, forced-dose-escalation study. Clin Ther 28:402Y418 72

Biederman J, Heiligenstein JH, Faries DE, et al., for the Atomoxetine ADHD Study

Group. Efficacy of atomoxetine versus placebo in schoolage girls with attention-

deficit/hyperactivity disorder. Pediatrics. 2002;110(6):e75. 73

Michelson D, Allen AJ, Busner J, et al. Once-daily atomoxetine treatment for children

and adolescents with attention deficit hyperactivity disorder: a randomized, placeo-

controlled study. Am J Psychiatry. 2002;159(11):1896-1901. 74

Greenhill LL, Pliszka S, Dulcan MK, et al., for the American Academy of Child and

Adolescent Psychiatry. Practice parameter for the use of stimulant medications in the

treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry.

2002;41(2 suppl):26S-49S.

52

75

Reiff MI, Tippins S. ADHD: A Complete and Authoritative Guide. Elk Grove Village,

Ill.: American Academy of Pediatrics; 2004. 76

Shelton TL, Barkley RA. The role of parent training groups in the treatment of

attention deficit hyperactivity disorder. Child Adolesc Psychiatr Clin North Am

1992;1:519-36. (Class R) 77

Balint S, CzoborP., Meszaros A, Simon V, Bitter I(2008). [ Neuropsychological

impairments in adult attention deficit hyperactivity disorder: a literature review]” (in

Hungarain). Psychiatr Hung 23. 78

Nair J, Ehimare U, Beitman BD, Nair SS, Lavin A(2006) “ Clinical review: avidence-

based diagnosis and treatment of ADHD in children”. Mo Med 103.

14. avtorTa jgufi

klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier

avtorebi: nino kiknaZe (ojaxis eqimi), eka faRava (ojaxis eqimi), qeTevan nemsaZe (pediatri), gia meliqiSvili (bavSvTa nevrologi), guram kiknaZe (redaqtori), givi javaSvili (redaqtori).

eqspertebi:

saqarTvelos saojaxo medicinis profesionalTa kavSiri;

saqarTvelos pediatriis akademia;

lela woworia _ saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti;

Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti;

Tamar ZagniZe _ saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti.