常见的儿童心智问题课件.ppt

1、台中榮民總醫院精神部侯伯勳醫師l症狀 時間 嚴重度l多專業l生物 心理 社會l多元化治療 療育l是過程或疾患l考慮發展l父母 老師 手足 同儕 媒體 身體狀況等多因素影響發展l可塑性高l1902,George Frederic Still,M.D.proposed that defiance,excessive emotion,and impaired inhibition in children were most likely caused by genetic dysfunction and not by poor child rearing as many people previou

2、s believel1937,pediatrician Charles Bradley used stimulants to treat ADHD-like symptom lMinimal brain damagelMinimal brain dysfunctionlHyperkinetic syndrome in ICD-9lADHD in DSM-IIIRlADHD-I,ADHD-HI,ADHD-C in DSM-IVl經常無法密切注意細節，或在學校作業、工作、或其他活動上經常粗心犯錯l在工作或遊戲活動時經常有困難維持注意l經常看來不專心聽別人正對他說的話l經常不能照指示把事情做完，並且

3、不能完成學校作業、家事零工、或工作場所的職責l經常有困難規劃工作及活動l經常逃避、不喜歡、或排斥參與需全神貫注的任務l經常遺失工作或活動必備之物l經常容易受外界刺激影響而分心l在日常活動經常遺忘事物 l經常手忙腳亂或坐時扭動不安l需坐好之場合經常離座l在不適當之場合四處奔跑或攀爬l經常有困難從事安靜的遊玩或休閒l經常處於活躍狀態，難以安靜l經常說話過多l問題未說完即強答l需輪流時經常無法等待l經常打斷或侵擾別人l過動、易衝動的症狀有六項或六項以上l 症狀超過六個月、在七歲以前、兩種場所以上出現，造成學業、社會等功能損害。DSM-IVlInterview with parentslSchool

4、informationlRating scalelChildren diagnostic interview&observationlReferred:IQ,CPT,speech evaluation,occupational therapy evaluation lThe average age at onset is 3 or 4 yrslSymptoms generally evolve as he or she ages.Ex:from hyperactivity to restlessness J Clin Psychiatry March 2003 l差異性大lDSM-IV:3-5

5、%in school aged childrenlStudies:3-20%(Taiwan:11.7%)l男童多於女童(hospital sample)lUnclearlFrontal,parietal,frontostriatal lNeurotransmitter dysregulation:dopamine,5-HT,NAlGenetic factorl brain image study:basal ganglia,corpus callosum seems to be involved.lfMRI:abnormal activation in parietal&frontal are

6、aslPET:decrease in brain metabolism of the basal ganglia lAdoption study:7.5%of the biological parents of the adopted-away hyperactive children were themselves hyperactive as compared to 2.1%in the adopting parents.lTwin study:monozygotic 51%,dizygotic 33%Etiology-geneticslHigher risk for ADHD in si

7、bling of ADHD probands(20.8%),than in siblings of normal probands(5.6%)lSingle neurotransmitter abnormaly is not likelylDopamine,norepinephrine,serotonin may influence behavior problems.lImpaired delayed respondinglAn impairment in response inhibition,difficulty self regulation response to stimuli.l

8、3-9%,recent studiesl30-85%of children with add continue to have problem during their adolescent,&early adulthoodlHighly heritable,4.6-7.6 fold increased risk for first degree relatives J Clin Psychiatry March 2003 lMay contribute to the severity,comorbidity&outcome.lConduct disorder,oppositional def

9、iant disorderlLearning disabilitylTicslDepressionlAnxiety disorderlPervasive developmental disorderlMental retardationl studies focus on young male,combined type.lEducational outcomes:low grade,dropout.Only 5%of ADHD patient who entered college can graduatedlEmployment Outcomes:3times more likely to

10、 be fired than individual without ADHD lDriving:Forty percent of drivers with ADHD have at least 2 accidents by young adult compared with only 6%of drivers without ADHD,3 times more the dollars damage amount for accident.lSexual&reproductive outcomes:high rate of teen pregnancy&sexually transmitted

11、disease lHealth care outcomes:increase health care costs even when control psychiatric treatment.More major injury,asthma.lNot a benign disorder that disappears after childhood.Journal of clinical psychiatry,2002 lCNS stimulantslAntidepressants:TCA,bupropionlClonidinelAtomoxetine1.環境控制：保持單純、整潔的環境，避免

12、過多刺激干擾注意力。2.注意力集中訓練：進行須注意力集中之活動，如拼圖、積木、聽音樂等，循序漸進，逐步延長時間。3.有效能的行為管理（重點、堅持、一致、鼓勵）：這些孩子常有許多不恰當的行為，需有效能的行為管理；把握重點，勿過於瑣碎，堅持而一致的態度，多鼓勵其良好表現。lBehavioral modification:Positive reinforcement,Withdrawal reward,Timeout(1 min for per yr of age),token economy techniquelShort term effect,need to be maintain lEnvi

13、ronment modification:Structure,closed supervision,limiting distractions.lParents&teachers enrolled in treatment planlMedication l合併症的治療:Tics,MR,Autisml臺灣治療現狀lManagement of ADHD in adults.lCommon disorderlPrevalence11.7%(6.3%in Taichung local study)lLots of patient did not undergo evaluation or treat

14、ment lFamily education is in need 中榮研究中榮研究2002lCompared 1987,1997lThe rate of outpatient treatment for add increased from 0.9 per 100 children to 3.4 per 100 childrenlLargest increase in low economic statue familySignificant decrease in the number of treatment visits,significant increase in the number of stimulants prescriptions Am J of psychiatry 2003;160,1071-1077