1、雙障是否存在雙障是否存在?智障+多動症=雙障 有初步證據表明，多動症在智障兒童中是有效的精神診斷 智障+多動症 易出現認知功能某些方面的缺失References:Antshel,K.M.,Phillips,M.H.,Gordon,M.,Barkley,R.,&Faraone,S.V.(2006)Is ADHD a valid disorder in children with intellectual delays?Clinical Psychology Service,26,555-572.Rose,E.,Bramham,J.,Young,S.,Paliokostas,E.,Xenitidi
2、s,K.(2009)Research in Developmental Disabilities,30,496-502.CONFIDENTIAL雙障雙障(兒童兒童)智障兒童處於多動症增加的風險 興奮劑藥物可能成功治療症狀 年齡較小的兒童，自閉症的診斷，有更多的多動症的症狀Reference:Hastings,R.P.,Beck,A.,Daley,D.,&Hill,C.(2005).Symptoms of ADHD and their correlates in children with intellectual disabilities.Research in Developmental D
3、isabilities,26,456-468.雙障雙障(青少年青少年)智障青少年繼續處於多動症增加的風險 智障青少年+多動症：智障青少年風險比 3.38：1 智障青少年和非智障青少年多動症症狀的出現相似Reference:Neece,C.L.,Baker,B.L.,Crnic,K.,&Blacher,J.(2013).Examining the validity of ADHD as a diagnosis for adolescents with intellectual disabilities:clinical presentation.Journal of Abnormal Child
4、 Psychology,41,597-612.Introduction to ADHD什麼是什麼是ADHDInattention專注力不足專注力不足Hyperactivity過度活躍過度活躍Impulsivity衝動行為衝動行為Symptoms of ADHD 徵狀徵狀ADHD brief definition 簡單定義簡單定義Disorders characterized by levels if inattention,hyperactivity and impulsivity that are inconsistent with the level of development of t
5、he child,adolescent or adult 小朋友、青少年或成年人如果出現與他們的成長期不相乎的專注力問題、過度活躍和衝動行為 便有可能患上 ADHD。ADHD brief definition簡單定義簡單定義Symptoms persisted for at least 6 months 徵狀最少持續6個月Symptoms present before the age of 12 years 徵狀於12歲前出現Criteria must be met in more than 2 situation (at home,school,or work,with friends or
6、 relatives)必須在多於2個環境下符合以上徵狀準則 (在家,學校,工作間,與朋友及親友相處)Clinically significant distress or impairment in social,academic or occupational functioning 影響到社交、學業或工作Maladaptive and inconsistent with developmental level 與正常人發展程度不相符Data extracted from DSM-V criteriaCORE SYMPTOMS 主要徵狀主要徵狀but they can also have ma
7、ny strengths但其實但其實ADHD 的小朋友都有很多不同的長處的小朋友都有很多不同的長處Dpfner et al 2000,2002.they can be extremely intelligent他們可以是他們可以是”超級聰明超級聰明”的的Open-minded持開放態度持開放態度Excitable時常都興奮時常都興奮Energetic充滿活力充滿活力Fun to be with與他們相處很有趣與他們相處很有趣DSM-V Diagnostic CriteriaDSM-V 斷症準則斷症準則CONFIDENTIALInattention Symptoms(at least 6 sym
8、ptoms required)專注力不足徵狀專注力不足徵狀(最少符合最少符合6項項,成人最少符合成人最少符合 5 項項)Fails to give close attention to details or makes careless mistakes in schoolwork,work,etc.難以注意細節，容易因此犯錯難以注意細節，容易因此犯錯Difficulty sustaining attention 難以長時間專注於同一件事情，如：學習、日常活動、遊戲難以長時間專注於同一件事情，如：學習、日常活動、遊戲 Does not seem to listen when spoken to
9、 directly 難以細心聆聽別人的說話難以細心聆聽別人的說話Does not follow through on instructions and fails to finish schoolwork,chores,etc.難以按照指引做事，經常無法完成日常事務難以按照指引做事，經常無法完成日常事務Difficulty organizing tasks and activities 做事經常缺乏條理，做事經常缺乏條理，難以妥善安排如有關學習、活動、生活等方面的計劃難以妥善安排如有關學習、活動、生活等方面的計劃 Avoids tasks requiring sustained mental
10、effort 抗拒或不喜歡那些需要全神貫注的事情抗拒或不喜歡那些需要全神貫注的事情 Loses things necessary for tasks or activities 經常遺失日常學習或活動的所需用品經常遺失日常學習或活動的所需用品 Easily distracted by extraneous stimuli 很容易受週遭環境或事情影響而分心很容易受週遭環境或事情影響而分心 Forgetful in daily activities 常遺忘日常生活中已安排的活動，如忘記約會的時間常遺忘日常生活中已安排的活動，如忘記約會的時間ADHD Diagnostic Criteria(cont
11、.)DSM-V 斷症準則斷症準則(續續)Hyperactivity-Impulsivity Symptoms 過度活躍、衝動行為徵狀過度活躍、衝動行為徵狀 (at least 6 symptoms required)(最少符合最少符合6項項,成人最少符合成人最少符合5 項項)Difficulty playing or engaging in activities quietly 難以安靜地遊玩或參與休閒活動Always on the go or acts as if driven by a motor”無時無刻也在活動，像一部不會停下來的機器Talks excessively 多言Blurts
12、 out answers 問題還未問完，他們便搶著回答Difficulty waiting in lines or awaiting turn 難以在遊戲或群體中輪候或排隊 Interrupts or intrudes on others 常中途打擾或騷擾別人的活動 Runs about or climbs inappropriately 在不適當的場合四處跑或攀爬Fidgets with hands or feet or squirms in seat 常手舞足蹈，或在座位上不停地扭來扭去，難以安靜下來Leaves seat in classroom or in other situatio
13、ns in which remaining seated is expected 在課室或需要安坐的場合，經常擅自離座CONFIDENTIALADHD Diagnostic Criteria(cont.)斷症準則斷症準則(續續)Symptoms present before age 12 徵狀於12歲前出現Clinically significant impairment in social or academic/occupational functioning 影響到社交、學業或工作Some symptoms that cause impairment are present in 2 o
14、r more settings(e.g.,school/work,home,recreational settings)在兩個平時活動的 2個或以上範疇出現症狀Not due to another disorder(e.g.,Mood Disorder,Anxiety Disorder)出現的症狀並非由其它病引致的(例:情緒失調、焦慮症)CONFIDENTIALCONFIDENTIALCombined Type複合型複合型Clinical levels of both inattention and hyperactivity/impulsivity臨床同時出現“專注力失調”和“過度活躍/衝動
15、型”Most common subtype最常見的類型Predominantly Inattentive Presentation 專注力不足型專注力不足型Clinical levels of inattention only 臨床只只有專注力不足型 Often not identified until middle school 通常要到中學時期才被發現Sluggish cognitive tempo 認知速度遲緩Predominantly Hyperactive/Impulsive Presentation 過度活躍過度活躍/衝動型衝動型Clinical levels of hyperac
16、tivity/impulsivity only 臨床出現過度活躍或衝動型More common among very young children prior to school entry 普遍見於未入學的幼童(於香港/澳門剛入小學的時候)ADHD CLASSIFICATION分類分類DSM-V DIAGNOSES(ADHD)Diagnostic Issues in DSM V(For adolescents and adults)For the diagnosis of adolescents and adults:青少年和成人的診症:For older adolescents and a
17、dults(age 17 and older),at least five symptoms are required.對於青少年和成人(17歲及以上)最少需符合5個徵狀 Several inattentive or hyperactive impulsive symptoms were present prior to age 12 years.於12歲前,巳出現有數個專注力失調 或過度活躍/衝動型的徵狀In adults,hyperactivity may manifest as extreme restlessness or wearing others out with their a
18、ctivity 就成人來說 過度活躍可以是極度坐立不安或煩擾他人的行為 (未必一定是如小童般過動)Impulsivity may manifest as social intrusiveness(e.g.,interrupting others excessively)and/or as making important decisions without consideration of long term consequences(e.g.,taking a job without adequate information).衝動行為能被視為干擾社交的行為(例:過份地打擾他人)和/或未考慮
19、長遠後果而作出重要決定 (例:接受一份未了解工作性質的工作)CONFIDENTIALCONFIDENTIALNot all the ADHD kids have hyperactivity symptoms!不是每個不是每個 ADHD孩童都孩童都有過度活躍徵狀有過度活躍徵狀!(People easily misunderstand this as the only symptom)(大眾容易誤認為過大眾容易誤認為過度活躍度活躍是唯一徵狀是唯一徵狀)Inattention is always missed out!專注力不足往往不容易被察覺而被怱略專注力不足往往不容易被察覺而被怱略!ADHD:B
20、iological Basis生理基礎生理基礎Misconception that ADHD is due to bad parenting despite biological basis of the disorderADHD常被誤解為行為問題常被誤解為行為問題,或是家長管教的問題或是家長管教的問題!其實其實ADHD 大部份是生物因素形成的問題大部份是生物因素形成的問題.Genetic Basis of ADHD基因基因Evidence from:Family studies Adoption studies Twin studies Molecular genetics(identifi
21、ed genes include:DRD4,DAT1,DRD5,DBH,5HT1b,C4b)00.20.40.60.811.2Willerman 1973Goodman 1989Gillis 1992Edelbrock 1992Schmitz 1995Thapar 1995Gjone 1996Silberg 1996Sherman 1997Levy 1997Nadder 1998HeritabilityADHD Symptom Scores are Highly Heritable 高度遺傳性高度遺傳性!指數愈接指數愈接近近“1”,代表代表 100%來來自遺傳自遺傳所以所以ADHD 小朋友小朋
22、友,很很多時候他們多時候他們的家長也有的家長也有ADHD!Interaction between Genes and Family Environment 基因和家庭環境之相互關係基因和家庭環境之相互關係 Influence of parenting on child 家庭教育對孩童的影響 Antisocial parents provide environments with harsh and inconsistent reactions which affect the childs behaviour 激進(反社會)的父母塑造了苛刻和非協調的環境,從而影響了孩童的行為 Influenc
23、e of children on parents 孩童對父母的影響 Children with antisocial behaviour can induce negative parenting.Stimulant therapy of child has been shown to alter parental behaviour而有激進(反社會)行為的孩童會引致不良的家庭教育!刺激物治療法對孩童可有效改善變父母的家庭教育行為Neuroimaging Findings神經影像發現神經影像發現.Changes in some brain areas ADHD 患者腦部的改變 Castella
24、nos et al.,1996 Castellanos et al.,2001 Durston et al.,2005 Reduction of about 5%towards brain volume in ADHD patients ADHD 患者的腦容量會比正常人細少約5%Aetiology:Neuroanatomy total brain volumeAdapted from EINAQ,Castellanos et al 2002EINAQ:European Interdisciplinary Network for ADHD Quality Assurance在腦部發展的任何時期在
25、腦部發展的任何時期,不分男女不分男女,ADHD 患者的腦容量都是比正人為小患者的腦容量都是比正人為小智障青少年智障青少年多動症多動症的生物相關因素的生物相關因素 不管青少年的認知能力，青少年多動症的症狀與父母多動症的症狀相關 DRD4基因變異和青少年組轉移的能力與青少年多動症的症狀相關，獨立於認知功能Reference:Neece,C.L.,Baker,B.L.,&Lee,S.S.(2013)ADHD among adolescents with intellectual disabilities:pre-pathway influences.Research in Developmental
26、 Disabilities,34,2268-2279.Etiological Factors ADHD 的病因的病因CONFIDENTIALEtiological Factors病因病因CONFIDENTIALAverage heritability of 0.80-0.85(遺傳指數高達遺傳指數高達 0.80 0.85Environmental factors are not the cause,but may contribute to the expression,severity,course,and comorbid conditions 環境因素並非病因,不會有機會影響病的表徵,嚴
27、重性,長遠對患者的影響Dysfunction in prefrontal lobes 腦前葉的功能失常Involved in inhibition,executive functions 負責抑制能力及組織協調能力Genes involved in dopamine regulation 基因因素Dopamine transporter(DAT1)gene implicated7 repeat of dopamine receptor gene(DRD4)implicatedGene x environment interactionsPossible differences in size
28、of brain structures腦結構大小的差別 Prefrontal cortex,Corpus callosum,caudate nucleusAbnormal brain activation during attention&inhibition tasks 在需要專注力或處理抑制行為,出現不正常的腦部活動Brain Structure&Function腦部結構和功能腦部結構和功能CONFIDENTIALDifferences in brain maturation,structure,function(particularly abnormalities in frontost
29、riatal circuitry):Prefrontal cortexBasal gangliaCerebellumThese areas of the brain are associated with executive function abilities:Attention,spatial working memory,and short-term memoryResponse inhibition and set shifting腦部不同部份負責不同工作腦部不同部份負責不同工作.Neurotransmitters 神經傳遞物質CONFIDENTIALNeurotransmitter
30、differences,particularly in levels of:神經接收器的落差Dopamine多巴胺多巴胺Norepinephrine 正腎上腺素正腎上腺素Epinephrine腎上腺素Serotonin血清素Dopamine has been associated with approach and pleasure-seeking behaviors 多巴胺常被介定為:與親近別人及尋求歡樂的行為有關Norepinephrine plays a role in emotional/behavioral regulation 正腎上腺素能影響情緒和行為的控制多巴胺是相當重要神經傳
31、遞物質多巴胺是相當重要神經傳遞物質.ADHD 患者的多巴胺水平就是不足患者的多巴胺水平就是不足,因而出現各種專注力因而出現各種專注力&過店活躍過店活躍/衝動行為衝動行為Executive Functioning Deficits執行功能的缺少執行功能的缺少CONFIDENTIALCognitive processes which activate,integrate,and manage other brain functions 認知過程能影響其它腦部功能Examples:例子例子:Cognitive:working memory,planning,use of organizational
32、 strategies 認知能力:工作記憶、計劃、組織策略Language:verbal fluency,communication 語言能力:語言流暢度、溝通Motor:response inhibition,motor coordination 反應能力:抑制、協調 Emotional:self-regulation of emotion,frustration tolerance 情感能力:情緒自制Controversial issues:爭議點爭議點:EF deficits overlap with ADHD symptoms 執行功能的缺少與ADHD徵狀同時出現EF deficits
33、 are not unique to ADHD 執行功能的缺少缺少不是ADHD獨有的Not all children with ADHD have EF deficits不是所有患上ADHD的孩童都有執行功能的缺少A Possible Developmental Pathway for ADHD(ADHD 發病圖發病圖)CONFIDENTIALFrom Mash&Wolfe,2007基因危基基因危基不能正常地作出抑制不能正常地作出抑制正面腦葉及腦部基底正面腦葉及腦部基底核不正常核不正常多巴胺傳多巴胺傳遞受干擾遞受干擾懷孕時受酒精、煙草懷孕時受酒精、煙草或其它影響或其它影響出現認知缺憾於記憶力、
34、語言能力和出現認知缺憾於記憶力、語言能力和自我控制力自我控制力出現專注力不足、過度活躍和衝動行出現專注力不足、過度活躍和衝動行為徵狀為徵狀出現社交和學業發展的缺失出現社交和學業發展的缺失家庭教育家庭教育(養育養育)被干擾被干擾出現對抗性反叛和品格障疑的徵狀出現對抗性反叛和品格障疑的徵狀通常通常ADHD被發現的時被發現的時候候,巳經是較遲的階段巳經是較遲的階段ADHD:Prevalence and Demographics發病率和人口分佈性發病率和人口分佈性 Overall prevalence 3%to 10%in school-aged children internationally 國際
35、性資料顯示,3%至10%適齡學童會患上此病 Diagnosed in boys 3 to 4 times more often thanin girls 男孩患者比女孩患者高3至4倍 Persists in 30%to 50%of patients into adolescence and adulthood(symptom profile may change)30%至50%患者會持續患病至青少年和成年期Commodities that ADHD kids sufferADHD會引致甚麼後果？會引致甚麼後果？CONFIDENTIALDefining Comorbidity複病症複病症(同時有
36、其他病症同時有其他病症)定義定義 ADHD is highly comorbid ADHD 是高度複病症性(很容易會同時有其他病症)Comorbidity is defined as two different diagnoses present in an individual patient 複病症性是指兩種不同診斷的病症出現於同一個病人 It is important to recognize comorbid disorders 了解複病症的問題很重要 Comorbidities may require treatment independent from and different
37、to therapy for ADHD 複病症性可能需要獨立和有別於ADHD診療的治療CONFIDENTIALAssociated Problems相關問題相關問題Peer problems 同輩問題同輩問題Inattentive symptoms ignored專注力不足徵狀被怱略Hyperactive/impulsive symptoms actively rejected 過度活躍/衝動徵狀被否定Not deficient in social reasoning/understanding,but rather the execution of appropriate social be
38、havior 並非社交認知不足,而是不能做出適當的社交行為Family dysfunction/parental issues家庭方面家庭方面No clear causal relationship between family problems and ADHD 家庭問題和ADHD並無清晰關係Family problems can impact the severity and developmental course/outcomes of ADHD 家庭問題能影響ADHD的發展和嚴重性Self-esteem自尊心自尊心Inflated:Positive illusory bias(Hoz
39、a)自尊心過高:正面偏見Low self esteem associated with comorbid depression自尊心低落:抑鬱症複病症Co-occurring Disorders in Children(n=579)於孩童出現的多種病症於孩童出現的多種病症Oppositional Defiant Disorder40%Tics11%Conduct Disorder14%ADHD alone31%Anxiety Disorder 34%Mood Disorders 4%MTA Cooperative Group.Arch Gen Psychiatry 1999;56:108810
40、96 情緒障礙情緒障礙只有只有ADHDADHD:Comorbid Conditions複症狀複症狀Milberger et al.Am J Psychiatry 1995:152:17931799Biederman et al.J Am Acad Child Adolesc Psychiatry 1997;36:2129Castellanos.Arch Gen Psychiatry 1999;56:337338 Goldman et al.JAMA 1998;279:11001107 Szatmari et al.J Child Psychol Psychiatry 1989;30:21923
41、0Tics(%)6040200OppositionaldefiantAnxietyLearningMoodConductdisorderSmokingSUD對抗性對抗性反判反判焦慮症焦慮症學習學習情緒情緒品格障礙品格障礙吸煙吸煙手腳震手腳震動動自殺自殺 艱辛的道路艱辛的道路學前階段學前階段 3-6 3-6 歲歲u很快便轉換遊戲u身體活動停不下來u社交困難嬰兒嬰兒/幼童階段幼童階段 0-3 0-3 歲歲u 容易煩躁容易煩躁 u 睡眠不安睡眠不安u 不服從不服從小學階段小學階段 6-126-12歲歲 u 容易分心容易分心u 衝動及破壞性的行為衝動及破壞性的行為u 學習及社交困難學習及社交困難 u
42、自信心低自信心低 青少年階段青少年階段u 學習困難u 人際關係的問題u 難以計劃事情u 侵略/攻擊性行為13-17歲歲u 對抗性行為u 濫用藥物/酒精u 冒險行為 成人階段成人階段u 人生欠缺目標u 自尊心低落u 人際關係的問題u 情緒病u 睡眠問題18歲以上歲以上u 忽略健康u 衝動性行為u 濫用藥物/酒精u 危險駕駛u 財政困難ADHD 延醫的後果延醫的後果對兒童的影響對兒童的影響ADHD過度活躍過度活躍衝動衝動專注力弱專注力弱被家人斥責被家人斥責同輩排斥同輩排斥常常做出危險行常常做出危險行為和錯誤決定為和錯誤決定成績不理想成績不理想自尊心低落自尊心低落情緒困擾情緒困擾ADHD 延醫的後果
43、延醫的後果ADHD兒童兒童的負面行為的負面行為夫婦因管教問夫婦因管教問題爭執題爭執父母常要責備父母常要責備子女子女常被老師、親常被老師、親友設訴子女的友設訴子女的不良行為不良行為夫婦出現感情夫婦出現感情問題問題親子關係疏離親子關係疏離父母承受多方父母承受多方面厭力面厭力家庭關係差家庭關係差失去互信基礎失去互信基礎對家庭的影響對家庭的影響我們應如何處理我們應如何處理ADHD?家長對家長對ADHD治療的迷思治療的迷思我帶個仔去睇醫生，咪即係承認佢有病我帶個仔去睇醫生，咪即係承認佢有病!俾人睇到俾人睇到佢食藥，會歧視我個仔佢食藥，會歧視我個仔我個仔咁細就叫佢食藥，我個仔咁細就叫佢食藥，會唔會好多副作
44、用會唔會好多副作用架架會唔會食到鈍左架會唔會食到鈍左架大左大左又又會唔會身體唔好會唔會身體唔好聽講有個音樂治療班，唔知會唔會好過食藥呢聽講有個音樂治療班，唔知會唔會好過食藥呢?阿仔啲行為真係好似阿仔啲行為真係好似ADHD，但係都係觀察多一，但係都係觀察多一陣先決定醫唔醫陣先決定醫唔醫可能過一年半載無事呢可能過一年半載無事呢ADHD 治療 藥物治療 行為治療 認知行為治療 感覺統合治療 社交訓練40EFFICACY OF INTERVENTIONSSymptomatic normalisation ratesin the MTA studyCommunitytreatmentMEDMED+Beh
45、avioural treatmentBehavioural treatmentSwanson et al 2001藥物及行為治療藥物及行為治療藥物治療是必須的藥物治療是必須的(因為是腦部因為是腦部問題問題),配合行為治療是較有效配合行為治療是較有效處理處理ADHD的方案的方案,效果更理想效果更理想社區治療社區治療行為治療行為治療藥物治療藥物治療NICE Guidelines(UK)CONFIDENTIALADHD患者須接受包含藥物、心理、行為及教育等全面治患者須接受包含藥物、心理、行為及教育等全面治療療Methylphenidate為第一線的為第一線的 ADHD 藥物藥物鹽酸甲酯鹽酸甲酯 (M
46、ethylphenidate)(Methylphenidate)藥物藥效藥效一般鹽酸甲酯4-8小時(每日服2-3次)長效釋放劑型鹽酸甲酯12小時(每日1次)作為第一線藥物治療作為第一線藥物治療 ADHD 1長效長效藥可改善藥可改善:1小朋友忘記服藥的問題小朋友忘記服藥的問題 避免孩子因經常於同學面前服藥而感到自卑和尷尬避免孩子因經常於同學面前服藥而感到自卑和尷尬 避免孩子因常服藥而覺得麻煩反感避免孩子因常服藥而覺得麻煩反感，同時父母不用，同時父母不用常常督常常督促服藥，照顧相對輕鬆促服藥，照顧相對輕鬆 小朋友能與家長建立更好的關係小朋友能與家長建立更好的關係1.)ADHD-NICE Guide
47、line 2008(National Institute for Health and Care Excellence)Releasing ProfileFull active day treatment coverage offers a number of benefits1Promotes overall wellbeing and resilienceDevelops both academic&social competenciesImproves role functioning in and out of schoolImproves family relationshipsLi
48、mited impact on sleepReduces risk of accidents1.Buitelaar and Medori Eur Child Adolesc Psychiatry 2010;19(4):325-40Safety Profile In two open-label,long-term safety trials(N=1514,up to 27 months):treatment discontinuation rate was low at 6.7%.adverse event profile was similar to that observed in sho
49、rter term trials.Effects of prolonged therapy with Concerta on growth are clinically insignificant.部份患者可能需要服食一些非刺激中樞神經藥物，例部份患者可能需要服食一些非刺激中樞神經藥物，例如；托莫西汀如；托莫西汀(Atomoxetine)(Atomoxetine)非一線藥物非一線藥物 小朋友的表現亦可有改善。這類藥物一般適用於對刺激小朋友的表現亦可有改善。這類藥物一般適用於對刺激中樞神經藥物無效的患者。中樞神經藥物無效的患者。1非刺激中樞神經藥物非刺激中樞神經藥物1.)ADHD-NICE Gu
50、ideline 2008(National Institute for Health and Care Excellence)一項隨機、雙盲、安慰劑對照研究，包括一項隨機、雙盲、安慰劑對照研究，包括113名兒童和名兒童和38名青少年名青少年ADHD RS總分總分（LSM 95%CI）擇思達擇思達安慰劑安慰劑P=.013*(n=51)(n=100)劑量劑量(/天天)*P=.001 *P=.003 *P.001 擇思達擇思達 在在12週內持續改善週內持續改善ADHDRS總分總分（LSM 95%CI）：）：由最小二乘法統計出的得分均數值由最小二乘法統計出的得分均數值。效應值效應值0.480.550.
