常見(jiàn)的兒童心智問(wèn)題課件

注意力不足過(guò)動(dòng)癥候群

:病因和預(yù)後臺(tái)中榮民總醫(yī)院精神部侯伯勳醫(yī)師注意力不足過(guò)動(dòng)癥候群

:病因和預(yù)後臺(tái)中榮民總醫(yī)院精神部1精神疾患癥狀時(shí)間嚴(yán)重度多專(zhuān)業(yè)生物心理社會(huì)多元化治療療育精神疾患癥狀時(shí)間嚴(yán)重度2兒童問(wèn)題特點(diǎn)是過(guò)程或疾患考慮發(fā)展父母老師手足同儕媒體身體狀況等多因素影響發(fā)展可塑性高兒童問(wèn)題特點(diǎn)是過(guò)程或疾患3何謂「過(guò)動(dòng)兒」？

何謂「過(guò)動(dòng)兒」？4History1902,GeorgeFredericStill,M.D.proposedthatdefiance,excessiveemotion,andimpairedinhibitioninchildrenweremostlikelycausedbygeneticdysfunctionandnotbypoorchildrearingasmanypeoplepreviousbelieve1937,pediatricianCharlesBradleyusedstimulantstotreatADHD-likesymptomHistory1902,GeorgeFredericS5常見(jiàn)的兒童心智問(wèn)題課件6TerminologyMinimalbraindamageMinimalbraindysfunctionHyperkineticsyndromeinICD-9ADHDinDSM-IIIRADHD-I,ADHD-HI,ADHD-CinDSM-IVTerminologyMinimalbraindamag7

注意力不良：以下有六項(xiàng)或六項(xiàng)以上經(jīng)常無(wú)法密切注意細(xì)節(jié)，或在學(xué)校作業(yè)、工作、或其他活動(dòng)上經(jīng)常粗心犯錯(cuò)在工作或遊戲活動(dòng)時(shí)經(jīng)常有困難維持注意經(jīng)?？磥?lái)不專(zhuān)心聽(tīng)別人正對(duì)他說(shuō)的話經(jīng)常不能照指示把事情做完，並且不能完成學(xué)校作業(yè)、家事零工、或工作場(chǎng)所的職責(zé)

注意力不良：以下有六項(xiàng)或六項(xiàng)以上經(jīng)常無(wú)法密切注意細(xì)節(jié)，或8注意力不良：以下有六項(xiàng)或六項(xiàng)以上經(jīng)常有困難規(guī)劃工作及活動(dòng)經(jīng)常逃避、不喜歡、或排斥參與需全神貫注的任務(wù)經(jīng)常遺失工作或活動(dòng)必備之物經(jīng)常容易受外界刺激影響而分心在日?；顒?dòng)經(jīng)常遺忘事物注意力不良：以下有六項(xiàng)或六項(xiàng)以上經(jīng)常有困難規(guī)劃工作及活動(dòng)9

過(guò)動(dòng)經(jīng)常手忙腳亂或坐時(shí)扭動(dòng)不安需坐好之場(chǎng)合經(jīng)常離座在不適當(dāng)之場(chǎng)合四處奔跑或攀爬經(jīng)常有困難從事安靜的遊玩或休閒經(jīng)常處?kù)痘钴S狀態(tài)，難以安靜經(jīng)常說(shuō)話過(guò)多過(guò)動(dòng)經(jīng)常手忙腳亂或坐時(shí)扭動(dòng)不安10易衝動(dòng)

問(wèn)題未說(shuō)完即強(qiáng)答需輪流時(shí)經(jīng)常無(wú)法等待經(jīng)常打斷或侵?jǐn)_別人易衝動(dòng)問(wèn)題未說(shuō)完即強(qiáng)答11過(guò)動(dòng)、易衝動(dòng)過(guò)動(dòng)、易衝動(dòng)的癥狀有六項(xiàng)或六項(xiàng)以上癥狀超過(guò)六個(gè)月、在七歲以前、兩種場(chǎng)所以上出現(xiàn)，造成學(xué)業(yè)、社會(huì)等功能損害。~DSM-IV過(guò)動(dòng)、易衝動(dòng)過(guò)動(dòng)、易衝動(dòng)的癥狀有六項(xiàng)或六項(xiàng)以上12AssessmentInterviewwithparentsSchoolinformationRatingscaleChildrendiagnosticinterview&observationReferred:IQ,CPT,speechevaluation,occupationaltherapyevaluationAssessmentInterviewwithparen13CharacteristicsTheaverageageatonsetis3or4yrsSymptomsgenerallyevolveasheorsheages.Ex:fromhyperactivitytorestlessness~JClinPsychiatryMarch2003CharacteristicsTheaverageag14Epidemiology差異性大DSM-IV:3-5%inschoolagedchildrenStudies:3-20%(Taiwan:11.7%)男童多於女童(hospitalsample)Epidemiology差異性大15EtiologyUnclearFrontal,parietal,frontostriatalNeurotransmitterdysregulation:dopamine,5-HT,NAGeneticfactorEtiologyUnclear16Etiology-brainimagebrainimagestudy:basalganglia,corpuscallosumseemstobeinvolved.fMRI:abnormalactivationinparietal&frontalareasPET:decreaseinbrainmetabolismofthebasalgangliaEtiology-brainimagebrainim17Etiology-geneticsAdoptionstudy:7.5%ofthebiologicalparentsoftheadopted-awayhyperactivechildrenwerethemselveshyperactiveascomparedto2.1%intheadoptingparents.Twinstudy:monozygotic51%,dizygotic33%Etiology-geneticsEtiology-geneticsAdoptionstud18Etiology-geneticsHigherriskforADHDinsiblingofADHDprobands(20.8%),thaninsiblingsofnormalprobands(5.6%)Etiology-geneticsHigherriskf19Etiology-neurochemistrySingleneurotransmitterabnormalyisnotlikelyDopamine,norepinephrine,serotoninmayinfluencebehaviorproblems.Etiology-neurochemistrySingle20ConceptualizationImpaireddelayedrespondingAnimpairmentinresponseinhibition,difficultyselfregulationresponsetostimuli.ConceptualizationImpaireddela21Prevalence3-9%,recentstudies30-85%ofchildrenwithaddcontinuetohaveproblemduringtheiradolescent,&earlyadulthoodHighlyheritable,4.6-7.6foldincreasedriskforfirstdegreerelatives

~JClinPsychiatryMarch2003Prevalence3-9%,recentstudies22Familial/environmentalfactorMaycontributetotheseverity,comorbidity&outcome.Familial/environmentalfactor23ComorbidityandDifferentialDiagnosisConductdisorder,oppositionaldefiantdisorderLearningdisabilityTicsDepressionAnxietydisorderPervasivedevelopmentaldisorderMentalretardationComorbidityandDifferentialD24Outcomes-1studiesfocusonyoungmale,combinedtype.Educationaloutcomes:lowgrade,dropout.Only5%ofADHDpatientwhoenteredcollegecangraduatedEmploymentOutcomes:3timesmorelikelytobefiredthanindividualwithoutADHDOutcomes-1studiesfocusony25Outcome-2Driving:FortypercentofdriverswithADHDhaveatleast2accidentsbyyoungadultcomparedwithonly6%ofdriverswithoutADHD,3timesmorethedollarsdamageamountforaccident.Sexual&reproductiveoutcomes:highrateofteenpregnancy&sexuallytransmitteddiseaseOutcome-2Driving:Fortypercen26Outcomes-3Healthcareoutcomes:increasehealthcarecostsevenwhencontrolpsychiatrictreatment.Moremajorinjury,asthma.Notabenigndisorderthatdisappearsafterchildhood.

~Journalofclinicalpsychiatry,2002Outcomes-3Healthcareoutcomes27TreatmentCNSstimulantsAntidepressants:TCA,bupropionClonidineAtomoxetineTreatmentCNSstimulants28如何幫助他？

1.

環(huán)境控制：保持單純、整潔的環(huán)境，避免過(guò)多刺激干擾注意力。2.

注意力集中訓(xùn)練：進(jìn)行須注意力集中之活動(dòng)，如拼圖、積木、聽(tīng)音樂(lè)等，循序漸進(jìn)，逐步延長(zhǎng)時(shí)間。3.

有效能的行為管理（重點(diǎn)、堅(jiān)持、一致、鼓勵(lì)）：這些孩子常有許多不恰當(dāng)?shù)男袨?，需有效能的行為管理；把握重點(diǎn)，勿過(guò)於瑣碎，堅(jiān)持而一致的態(tài)度，多鼓勵(lì)其良好表現(xiàn)。如何幫助他？1.

環(huán)境控制：保持單純、整潔的環(huán)境29TreatmentBehavioralmodification:Positivereinforcement,Withdrawalreward,Timeout(1minforperyrofage),tokeneconomytechniqueShorttermeffect,needtobemaintainTreatmentBehavioralmodificat30TreatmentEnvironmentmodification:Structure,closedsupervision,limitingdistractions.Parents&teachersenrolledintreatmentplanMedication

TreatmentEnvironmentmodificat31Discussion合併癥的治療:Tics,MR,Autism臺(tái)灣治療現(xiàn)狀ManagementofADHDinadults.Discussion合併癥的治療:Tics,MR,A32AddinTaiwanCommondisorderPrevalence11.7%(6.3%inTaichunglocalstudy)LotsofpatientdidnotundergoevaluationortreatmentFamilyeducationisinneed~中榮研究2002AddinTaiwanCommondisorder33TrentInUSACompared1987,1997Therateofoutpatienttreatmentforaddincreasedfrom0.9per100childrento3.4per100childrenLargestincreaseinloweconomicstatuefamilySignificantdecreaseinthenumberoftreatmentvisits,significantincreaseinthenumberofstimulantsprescriptions~AmJofpsychiatry2003;160,1071-1077

TrentInUSACompared1987,134注意力不足過(guò)動(dòng)癥候群

:病因和預(yù)後臺(tái)中榮民總醫(yī)院精神部侯伯勳醫(yī)師注意力不足過(guò)動(dòng)癥候群

:病因和預(yù)後臺(tái)中榮民總醫(yī)院精神部35精神疾患癥狀時(shí)間嚴(yán)重度多專(zhuān)業(yè)生物心理社會(huì)多元化治療療育精神疾患癥狀時(shí)間嚴(yán)重度36兒童問(wèn)題特點(diǎn)是過(guò)程或疾患考慮發(fā)展父母老師手足同儕媒體身體狀況等多因素影響發(fā)展可塑性高兒童問(wèn)題特點(diǎn)是過(guò)程或疾患37何謂「過(guò)動(dòng)兒」？

何謂「過(guò)動(dòng)兒」？38History1902,GeorgeFredericStill,M.D.proposedthatdefiance,excessiveemotion,andimpairedinhibitioninchildrenweremostlikelycausedbygeneticdysfunctionandnotbypoorchildrearingasmanypeoplepreviousbelieve1937,pediatricianCharlesBradleyusedstimulantstotreatADHD-likesymptomHistory1902,GeorgeFredericS39常見(jiàn)的兒童心智問(wèn)題課件40TerminologyMinimalbraindamageMinimalbraindysfunctionHyperkineticsyndromeinICD-9ADHDinDSM-IIIRADHD-I,ADHD-HI,ADHD-CinDSM-IVTerminologyMinimalbraindamag41

注意力不良：以下有六項(xiàng)或六項(xiàng)以上經(jīng)常無(wú)法密切注意細(xì)節(jié)，或在學(xué)校作業(yè)、工作、或其他活動(dòng)上經(jīng)常粗心犯錯(cuò)在工作或遊戲活動(dòng)時(shí)經(jīng)常有困難維持注意經(jīng)?？磥?lái)不專(zhuān)心聽(tīng)別人正對(duì)他說(shuō)的話經(jīng)常不能照指示把事情做完，並且不能完成學(xué)校作業(yè)、家事零工、或工作場(chǎng)所的職責(zé)

注意力不良：以下有六項(xiàng)或六項(xiàng)以上經(jīng)常無(wú)法密切注意細(xì)節(jié)，或42注意力不良：以下有六項(xiàng)或六項(xiàng)以上經(jīng)常有困難規(guī)劃工作及活動(dòng)經(jīng)常逃避、不喜歡、或排斥參與需全神貫注的任務(wù)經(jīng)常遺失工作或活動(dòng)必備之物經(jīng)常容易受外界刺激影響而分心在日常活動(dòng)經(jīng)常遺忘事物注意力不良：以下有六項(xiàng)或六項(xiàng)以上經(jīng)常有困難規(guī)劃工作及活動(dòng)43

過(guò)動(dòng)經(jīng)常手忙腳亂或坐時(shí)扭動(dòng)不安需坐好之場(chǎng)合經(jīng)常離座在不適當(dāng)之場(chǎng)合四處奔跑或攀爬經(jīng)常有困難從事安靜的遊玩或休閒經(jīng)常處?kù)痘钴S狀態(tài)，難以安靜經(jīng)常說(shuō)話過(guò)多過(guò)動(dòng)經(jīng)常手忙腳亂或坐時(shí)扭動(dòng)不安44易衝動(dòng)

問(wèn)題未說(shuō)完即強(qiáng)答需輪流時(shí)經(jīng)常無(wú)法等待經(jīng)常打斷或侵?jǐn)_別人易衝動(dòng)問(wèn)題未說(shuō)完即強(qiáng)答45過(guò)動(dòng)、易衝動(dòng)過(guò)動(dòng)、易衝動(dòng)的癥狀有六項(xiàng)或六項(xiàng)以上癥狀超過(guò)六個(gè)月、在七歲以前、兩種場(chǎng)所以上出現(xiàn)，造成學(xué)業(yè)、社會(huì)等功能損害。~DSM-IV過(guò)動(dòng)、易衝動(dòng)過(guò)動(dòng)、易衝動(dòng)的癥狀有六項(xiàng)或六項(xiàng)以上46AssessmentInterviewwithparentsSchoolinformationRatingscaleChildrendiagnosticinterview&observationReferred:IQ,CPT,speechevaluation,occupationaltherapyevaluationAssessmentInterviewwithparen47CharacteristicsTheaverageageatonsetis3or4yrsSymptomsgenerallyevolveasheorsheages.Ex:fromhyperactivitytorestlessness~JClinPsychiatryMarch2003CharacteristicsTheaverageag48Epidemiology差異性大DSM-IV:3-5%inschoolagedchildrenStudies:3-20%(Taiwan:11.7%)男童多於女童(hospitalsample)Epidemiology差異性大49EtiologyUnclearFrontal,parietal,frontostriatalNeurotransmitterdysregulation:dopamine,5-HT,NAGeneticfactorEtiologyUnclear50Etiology-brainimagebrainimagestudy:basalganglia,corpuscallosumseemstobeinvolved.fMRI:abnormalactivationinparietal&frontalareasPET:decreaseinbrainmetabolismofthebasalgangliaEtiology-brainimagebrainim51Etiology-geneticsAdoptionstudy:7.5%ofthebiologicalparentsoftheadopted-awayhyperactivechildrenwerethemselveshyperactiveascomparedto2.1%intheadoptingparents.Twinstudy:monozygotic51%,dizygotic33%Etiology-geneticsEtiology-geneticsAdoptionstud52Etiology-geneticsHigherriskforADHDinsiblingofADHDprobands(20.8%),thaninsiblingsofnormalprobands(5.6%)Etiology-geneticsHigherriskf53Etiology-neurochemistrySingleneurotransmitterabnormalyisnotlikelyDopamine,norepinephrine,serotoninmayinfluencebehaviorproblems.Etiology-neurochemistrySingle54ConceptualizationImpaireddelayedrespondingAnimpairmentinresponseinhibition,difficultyselfregulationresponsetostimuli.ConceptualizationImpaireddela55Prevalence3-9%,recentstudies30-85%ofchildrenwithaddcontinuetohaveproblemduringtheiradolescent,&earlyadulthoodHighlyheritable,4.6-7.6foldincreasedriskforfirstdegreerelatives

~JClinPsychiatryMarch2003Prevalence3-9%,recentstudies56Familial/environmentalfactorMaycontributetotheseverity,comorbidity&outcome.Familial/environmentalfactor57ComorbidityandDifferentialDiagnosisConductdisorder,oppositionaldefiantdisorderLearningdisabilityTicsDepressionAnxietydisorderPervasivedevelopmentaldisorderMentalretardationComorbidityandDifferentialD58Outcomes-1studiesfocusonyoungmale,combinedtype.Educationaloutcomes:lowgrade,dropout.Only5%ofADHDpatientwhoenteredcollegecangraduatedEmploymentOutcomes:3timesmorelikelytobefiredthanindividualwithoutADHDOutcomes-1studiesfocusony59Outcome-2Driving:FortypercentofdriverswithADHDhaveatleast2accidentsbyyoungadultcomparedwithonly6%ofdriverswithoutADHD,3timesmorethedollarsdamageamountforaccident.Sexual&reproductiveoutcomes:highrateofteenpregnancy&sexuallytransmitteddiseaseOutcome-2Driving:Fortypercen60Outcomes-3Healthcareoutcomes:increasehealthcarecostsevenwhencontrolpsychiatrictreatment.Moremajorinjury,asthma.Notabenigndisorderthatdisappearsafterchildhood.

~Journalofclinicalpsychiatry,2002Outcomes-3Healthcareoutcomes61TreatmentCNSstimulantsAntidepressants:TCA,bupropionClonidineAtomoxetineTreatmentCNSstimulants62如何幫助他？

1.

環(huán)境控制：保持單純、整潔的環(huán)境，避免過(guò)多刺激干擾注意力。2.

注意力集中訓(xùn)練：進(jìn)行須注意力集中之活動(dòng)，如拼圖、積木、聽(tīng)音樂(lè)等，循序漸進(jìn)，逐步延長(zhǎng)時(shí)間。3.

有效能的行為管理（重點(diǎn)、堅(jiān)持、一致、鼓勵(lì)）：這些孩子常有許多不恰當(dāng)?shù)男袨椋栌行艿男袨楣芾?；把握重點(diǎn)，勿過(guò)於瑣碎，