儿科学教学课件：注意力缺陷多动障碍

1Attention-deficit/

HyperactivityDisorder

(ADHD)注意力缺陷多动障碍2DefinitionADHDischaracterizedbyinattention,includingincreaseddistractibility注意力分散

anddifficultysustaining【持续的】attentionpoorimpulsecontrolanddecreasedself-inhibitorycapacity【自制能力】motoroveractivityandmotorrestlessness

注意力不集中【核心】，行为冲动，活动过度3EpidemiologyprevalenceofADHDacrosstheglobe:5-10%ofschool-agedchildren2-6%ofadolescent2%ofadults4ETIOLOGYGeneticfactorscandidategenes,eg:DAT1,DRD4Environmentfactorsbirthcomplicationsmaternalsmokingandalcoholuseduringpregnancyprenatalorpostnatalexposuretolead…Psychosocialfamily5PathogenesisAbnormalbrainstructuresarelinkedtoanincreasedriskofADHDdopaminehypothesis假设whichpostulatesthatdisturbancesinthedopaminesystemmayberelatedtotheonsetofADHD.多巴胺输送因子DAT1和多巴胺D1受体变异，失去对多巴胺的敏感性。6ClinicalmanifestationsHyperactivity

活动过度根本停不下来7SymptomsofHyperactivityFidgetswithhandsorfeetorsquirmsinseatLeavesseatinclassroomorinothersituationinwhichremainingseatedisexpectedRunsorclimbsexcessivelywheninappropriateHasdifficultyplayingorengaginginleisureactivitiesquietlyAlwaysonthegooractasifdrivenbyamotorOftentalksexcessivelyInadolescence,mayexhibitfeelingofrestlessness8Impulsivity行为冲动，不计后果Clinicalmanifestations9SymptomsofImpulsivityBlurtsoutanswersbeforequestionshavebeencompletedHasdifficultywaitinginturnInterruptsorintrudesonothers(forexamplebuttsintoconversationsorgames)10ClinicalmanifestationsInattention注意力不集中【核心症状】11SymptomsofInattentionFailstopaycloseattentiontodetailsormakescarelessmistakesHasdifficultymaintainingattentionintasksorplayactivitiesDoesnotseemtolistenwhenspokentodirectlyDoesnotfollowdirectionsandfailstocompleteschoolwork,chores,or,inadolescents,onthejobdutiesHasdifficultyorganizingtasksoractivitiesAvoidsordisliketaskthatrequiresustainedmentaleffortLossesthingsnecessaryfortaskoractivitiesEasilydistractedOftenforgetfulindailyactivities12ClinicalmanifestationsODD40%Mooddisorders38%CD14%TICs11%ADHD31%comorbidity伴随疾病13SUBTYPESOFADHD分类1.Predominantly主要的hyperactive/impulsivetype多动冲动为主型Achildmusthavesixormoresymptomsofhyperactivity/impulsivity2.Predominantlyinattentivetype注意力缺陷为主型Achildmustdisplaysixormoresymptomsofinattention3.Combinedtype混合型Achildmustshowsixormoresymptomsbothofinattentionandhyperactivity-impulsivity14DiagnosticEvaluation诊断评估ClinicalInterviewandHistoryEmphasizefactorsthatmightaffectthedevelopmentorintegrityofthecentralnervoussystemorrevealchronicillness,sensoryimpairments,ormedicationusethatmightaffectthechild’sfunctioning.Emphasizedisruptivesocialbehaviorswhichcanresultinhyperactiveoranxious.Emphasizeafamilyhistoryof1st-degreerelativeswithADHD,moodoranxietydisorders,learningdisability,antisocialdisorder,oralcoholorsubstanceabuse15DiagnosticEvaluationPhysicalExaminationTheclinicianshouldconsiderImpairedfinemotormovementandpoorcoordinationandothersoftarecommon(butnotsufficientlyspecifictocontributetoadiagnosisofADHD).identifyanypossiblevisionorhearingproblems.16DiagnosticEvaluationLaboratoryFindingsTherearenolaboratorytestsavailabletoidentifyADHDinchildren.TestforelevatedleadlevelsmaybeconsideredifthesechildrenareexposedtoenvironmentalfactorsComputerizedattentionaltasksandelectroencephalographicassessmentsarenotneededtomakethediagnosis.17DiagnosticEvaluationBehaviorRatingScalestheVanderbiltADHDDiagnosticRatingScaletheConnerRatingScales(parentandteacher)theADHDIndextheSwanson,Nolan,andPelhamChecklist(SNAP)Otherbroadbandchecklists,suchastheAchenbachChildBehaviorChecklist(CBCL),areusefulbutarenotsufficientalonetomakeadiagnosisofADHD.18DifferentialdiagnosisPSYCHOSOCIALFACTORSResponsetophysicalorsexualabuseResponsetoinappropriateparentingpracticesResponsetoparentalpsychopathologyResponsetoacculturationResponsetoinappropriateclassroomsettingMEDICALANDNEUROLOGICCONDITIONSThyroiddisorders(includinggeneralresistancetothyroidhormone)Heavymetalpoisoning(includinglead)AdverseeffectsofmedicationsEffectsofabusedsubstancesSensorydeficits(hearingandvision)AuditoryandvisualprocessingdisordersNeurodegenerativedisorderPost-traumaticheadinjuryPost-encephaliticdisorder19ManagementPsychosocialTreatments社会心理治疗theparentsandchildshouldbeeducatedTheclinicianshouldsetgoalsforthefamilytoimprovethechild’sinterpersonalrelationships,developstudyskills,anddecreasedisruptivebehaviors.20ManagementBehaviorallyOrientedTreatments行为导向疗法Recommended1stlinetreatmentisevidence-basedparent-and/orteacher-administeredbeha