儿童期疾患课件

儿童期疾患课件儿童期疾患课件儿童期疾患课件

ClassificationandDiagnosisofChildhoodDisorders

兒童期疾患的分類和診斷Developmentalpsychopathology發展的心理病理學Studiesdisordersofchildhoodwithinthecontextofnormalchilddevelopment在正常兒童發展的背景脈絡下研究兒童期的疾患Externalizingdisorders外化性疾患Characterizedbyoutwardbehaviors以外化性的行為為其特性Noncompliance,aggressiveness,overactivity,impulsiveness不服從,攻擊,過動,衝動Morecommoninboys在男孩較普遍Internalizingdisorders內化性疾患Characterizedbyinwardbehaviors以向化的行為為其特性Depression,anxiety,socialwithdrawal憂鬱,焦慮,社會退縮Morecommoningirls在女孩較普遍2Copyright2005JohnWiley&Sons,NY

ClassificationandDiagnosisofChildhoodDisorders

兒童期疾患的分類和診斷Developmentalpsychopathology發展的心理病理學Studiesdisordersofchildhoodwithinthecontextofnormalchilddevelopment在正常兒童發展的背景脈絡下研究兒童期的疾患Externalizingdisorders外化性疾患Characterizedbyoutwardbehaviors以外化性的行為為其特性Noncompliance,aggressiveness,overactivity,impulsiveness不服從,攻擊,過動,衝動Morecommoninboys在男孩較普遍Internalizingdisorders內化性疾患Characterizedbyinwardbehaviors以向化的行為為其特性Depression,anxiety,socialwithdrawal憂鬱,焦慮,社會退縮Morecommoningirls在女孩較普遍2Copyright2005JohnWiley&Sons,NYTable14.1ChaptersWhereDisordersareDiscussedThatOccurinBothChildrenandAdults

在兒童和成人身上皆會發生的疾患章節3Copyright2005JohnWiley&Sons,NYAttentionDeficit/HyperactivityDisorder

注意力不足/過動疾患Excessivelevelsofactivity過多的活動Fidgeting,squirming,runningaroundwheninappropriate,incessanttalking不安,扭動,不恰當的走動,不停的說話Distractabilityanddifficultyconcentrating分心和有困難集中Makescarelessmistakes,can’tfollowinstructions,forgetful粗心犯錯,不能聽從指令,健忘Mustbesevereandpersistent必須嚴重且持續Presentforatleast6monthsandcauseimpairmentsinfunctioning持續至少六個月並產生功能的受損4Copyright2005JohnWiley&Sons,NYAttentionDeficit/HyperactivityDisorder

注意力不足/過動疾患ThreesubcategoriesinDSM-IV-TR在DSM-IV-TR中可分為三個亞型：Predominantlyinattentivetype主要為不注意型Predominantlyhyperactive-impulsivetype主要為過動-易衝動型Combinedtype複合型Differentialdiagnosis鑑別診斷ADHDorConductDisorder?注意力不足過動疾患或品性疾患？ADHD注意力不足過動疾患Moreoff-taskbehavior,cognitive&achievementdeficits較多無法達成工作的行為,認知和成就上缺陷ConductDisorder品行疾患Moreaggressive,actoutinmostsettings,antisocialparents,familyhostility較多攻擊性,

常出現動作外化行為,反社會性父母,家人敵意5Copyright2005JohnWiley&Sons,NYAttentionDeficit/HyperactivityDisorder

注意力不足/過動疾患ADHDoftencomorbidwithanxietyanddepression通常和焦慮和憂鬱共病Prevalenceestimates2to7%盛行率估計約2到7％Symptomspersistbeyondchildhood症狀在兒童期之後仍持續Moststillmeetcriteriainadolescence大部分在青少年期仍符合準則6Copyright2005JohnWiley&Sons,NYEtiologyofADHD

注意力不足過動疾患的病因學Geneticfactors遺傳因素Twinstudies雙生子研究Heritabilityestimatesashighas70to80%遺傳率估計有百分之70到80高Twodopaminegenesimplicated二個多巴胺基因受到影響Neurobiologicalfactors神經生物因素Underresponsivefrontallobes額葉反應性低Reducedcerebralbloodflow大腦血流量減少Smallerfrontallobes,caudatenucleus,globuspallidus額葉,尾核和蒼白球較小7Copyright2005JohnWiley&Sons,NYEtiologyofADHD

注意力不足過動疾患的病因學Perinatalandprenatalfactors出生前後和產前因素Lowbirthweight出生體重低Maternaltobaccoandalcoholuse母親吸菸和酒精使用Environmentaltoxins環境毒素FoodadditivesandsugarnotrelatedtoADHD食品添加物和糖與注意力不足過動疾患沒有相關Nicotinefrommaternalsmoking來自母親吸煙所產生尼古丁Maydamagedopaminergicsysteminfetus可能損害胎兒多巴胺內生性系統8Copyright2005JohnWiley&Sons,NYEtiologyofADHD

注意力不足過動疾患的病因學PsychologicalFactors心理因素Ineffectiveparenting,negativeinteractions無效能的親職教育,負向互動Probablyinteractwithgeneticandneurobiologicalfactors可能和遺傳和神經生物因素產生交互影響LikelytoexacerbateormaintainADHDbehaviorsbutnotcausethem很可能惡化或維持ADHD的行為問題但不會造成此疾患9Copyright2005JohnWiley&Sons,NYTreatmentofADHD

注意力不足過動疾患的治療Stimulantmedications興奮劑藥物治療Reducedisruptivebehavior降低破壞性行為Improveattentionandconcentration改善注意力和專心Ritalin利他能AdderallConcertaStratteraSideeffects副作用Lossofappetite失去食慾Sleepproblems睡眠問題10Copyright2005JohnWiley&Sons,NYTreatmentofADHD

注意力不足過動疾患的治療Psychologicaltreatment心理治療Operantconditioning操作制約Parenttraining父母親訓練Classroommanagementandteachertraining課堂管理和老師的訓練Classroomstructure課堂結構Briefassignments簡短的作業Immediatefeedback立即回饋Task-focusedstyle聚焦於作業的方式Breaksforexercise中間休息以作運動11Copyright2005JohnWiley&Sons,NYConductDisorder(CD)

品行疾患Patternofengaginginbehaviorsthatviolatesocialnorms,therightsofothers,andareoftenillegal.從事違反社會規範,侵害他人權利和經常犯法的行為模式Aggression攻擊Crueltytowardsotherpeopleoranimals虐待他人或動物Lying說謊Stealing偷竊Vandalism暴力行為Oftenaccompaniedbylackofremorseandcallousness通常伴隨缺乏憐憫和無情12Copyright2005JohnWiley&Sons,NYOppositionalDefiantDisorder(ODD)

對立性反抗疾患ODDbehaviorsdonotmeetcriteriaforCDbutchilddisplayspatternofdefiantbehavior對立性反抗疾患的行為並不符合品行疾患的準則但兒童呈現反抗的行為模式Argumentative愛爭論的Losestemper脾氣不佳Lackofcompliance缺乏服從性Deliberatelyaggravatesother故意激怒他人Hostile,vindictive,spiteful,ortouchy充滿敵意,懷恨,惡意或暴躁的Blameothersfortheirproblems將自己的行為問題責怪他人Mostoftendiagnosedinboysbutmaybeasprevalentingirls通常診斷於男孩但女孩也可能很普遍13Copyright2005JohnWiley&Sons,NYConductDisorder(CD)

品行疾患Manytimesfirstidentifiedbylegalauthorities通常會先被法庭發現其問題行為‘Juveniledelinquents’青少年罪犯Substanceabusecommon普遍有物質濫用Comorbidwithanxietyanddepression,especiallyforgirls與焦慮和憂鬱共病,特別是針對女孩Prevalence盛行率Boys男孩4to16%百分比四到十六Girls女孩1.2to9%百分比ㄧ點二到九14Copyright2005JohnWiley&Sons,NYFigure14.1ArrestRatesAcrossAgesforHomicide,ForcibleRape,Robber,AggravatedAssault,andAutoTheft

殺人、強暴、搶劫、攻擊、偷車者在各年齡層的逮捕率15Copyright2005JohnWiley&Sons,NYConductDisorder(CD)

品行疾患Moffitt(1993)twopaths在1993年Moffitt所提的兩條發展路徑Life-course-persistent生命過程中持續出現Adolescence-limited僅在青少年期出現Notallaggressiveorconduct-disorderedboyscontinueaggressivebehaviorintoadulthood不是所有具攻擊性或品行疾患的男孩會持續攻擊行為到成年期Predictivefactors預測因子LowverbalIQ低語文智商Parentwithantisocialpersonalitydisorder父母有反社會人格疾患的問題Temperament天生氣質Dysfunctionalparent-childinteractions父母與孩子間不良的互動Poverty貧窮Lowsocialsupport低社會支持16Copyright2005JohnWiley&Sons,NYFigure14.2EtiologyofConductDisorder

品行疾患的病因學InsertFigure14.2品行疾患的病因學社會心理神經生物品行疾患17Copyright2005JohnWiley&Sons,NYEtiologyofConductDisorder(CD)

品行疾患的病因學Geneticfactors遺傳因素Heritabilitylikelyplaysapart遺傳可能扮演一部分因素Twinstudydatashowmixedresults雙生子研究資料呈現不一致的結果Adoptionstudiesfocusedoncriminalbehavior,notconductdisorder領養研究著重在犯罪行為，而非品行疾患的行為問題Evidenceforgeneticinfluence相關證據支持遺傳影響Geneticsandenvironmentinteract(Caspietal.,2002)遺傳和環境的交互影響AbuseasachildPLUSlowMAOAactivitymostlikelytodevelopCD虐待孩子加上低單胺氧化酶活性很可能發展品行疾患18Copyright2005JohnWiley&Sons,NYEtiologyofConductDisorder(CD)

品行疾患的病因學Neurobiologicalfactors神經生物因素Poorverbalskills語文技巧不佳Difficultywithexecutivefunctioning執行功能的困難LowIQ低智商Psychologicalfactors心理因素Deficientmoraldevelopment,especiallylackofremorse有缺陷的道德發展,特別是缺乏同情Modelingandreinforcementofaggressivebehavior攻擊行為的模仿和增強Harshandinconsistentparenting嚴格和不ㄧ致的教養方式Lackofparentalmonitoring缺乏父母的監控Cognitivebias(KennethDodge)認知偏誤Neutralactsbyothersperceivedashostile將他人的中性舉動知覺成有敵意的19Copyright2005JohnWiley&Sons,NYFigure14.3Dodge’sCognitiveTheoryofAggression

Dodge的攻擊認知理論Insertfigure14.3將模糊舉動解讀成有敵意對他人產生攻擊他人進行報復對他人產生更進ㄧ步攻擊20Copyright2005JohnWiley&Sons,NYEtiologyofConductDisorder(CD)

品行疾患的病因學Peerinfluence同儕影響Acceptanceorrejectionbypeers被同儕接受或拒絕Affiliationwithdeviantpeers與有偏差行為的同儕接近Socioculturalfactors社會文化因素Poverty貧窮Urbanenvironment都市的環境21Copyright2005JohnWiley&Sons,NYTreatmentofConductDisorder

品行疾患的治療Familyinterventions家人的介入Parentalmanagementtraining(PMT;GeraldPatterson)父母親管理訓練Teachparentstorewardprosocialbehavior教導父母獎賞利社會行為Cognitivetherapy認知治療Anger-controltraining憤怒控制訓練22Copyright2005JohnWiley&Sons,NYFigure14.4MultisystemicTreatmentofCD

品行疾患的多系統化治療InsertFigure14.423Copyright2005JohnWiley&Sons,NYDepressioninChildrenandAdolescents

兒童和青少年的憂鬱Symptomscommontochildren,adolescents,andadults兒童,青少年和成人的共同症狀Depressedmood憂鬱心情Inabilitytoexperiencepleasure無法經驗愉快Fatigue疲累Problemsconcentrating難以集中注意力Suicidalideation自殺意念Symptomsspecifictochildren&adolescents兒童和青少年的特定症狀Higherratesofsuicideattemptsandguilt較高比例的自殺嘗試和罪惡感Lowerratesof較低比例的Earlymorningawakening早晨易醒Earlymorningdepression早晨憂鬱Lossofappetite缺乏食慾Weightloss體重減少24Copyright2005JohnWiley&Sons,NYDepressioninChildrenandAdolescents

兒童和青少年的憂鬱Depressionrecurrent憂鬱持續再發Prevalence盛行率1%ofpreschoolers學齡前兒童為百分之ㄧ2–3%ofschoolagechildren學齡兒童為百分之二到三Adolescents青少年Girls女孩7–13%百分之七到十三2xthatofboys比男孩高於兩倍25Copyright2005JohnWiley&Sons,NYEtiologyofDepressioninChildrenandAdolescents

兒童和青少年憂鬱的病因學Geneticfactors遺傳因素Familyandrelationshipfactors家庭和人際關係因素Aparentwhoisdepressed父母有ㄧ方是憂鬱的Coldandhostilefamilyinteractions冷漠和敵意的家庭互動Poorsocialskills社交技巧不佳Impairedrelationshipswithpeersandsiblings和同儕和兄弟姐妹有不良的關係Parentalcriticism父母的批評26Copyright2005JohnWiley&Sons,NYTreatmentofDepressioninChildrenandAdolescents

兒童和青少年憂鬱的治療Muchlessresearchonchildhooddepression對於兒童憂鬱較少研究Medications藥物治療SSRIsmoreeffectivethantricyclics選擇性血清素抑制劑較三環抗鬱劑來得有效Concernsaboutincreasedriskofsuicideattempts自殺嘗試的風險增加CBTplusProzacmoreeffectivethaneitheralone認知行為治療加上百憂解比起單獨使用任何一種方式更為有效ProzacalonemoreeffectivethanCBTalone單獨使用百憂解比單獨使用認知行為治療更為有效Interpersonalpsychotherapy(IPT)人際關係心理治療CBTinschoolsetting學校環境的認知行為治療Treatmentofdepressedparent憂鬱父母的治療27Copyright2005JohnWiley&Sons,NYAnxietyinChildrenandAdolescents

兒童和青少年的焦慮Fearsandworriescommoninchildhood在兒童期害怕和憂慮很普遍Anxietydisorder焦慮疾患Moresevereandpersistentworry更為嚴重和持續性的憂慮Mustinterferewithfunctioning必須妨害日常生活功能Mostchildhoodfearsdisappearbutadultswithanxietydisordersreportfeelinganxiousaschildren大部分兒童時期害怕會逐漸消失但有焦慮疾患的成人報告當還是小孩時就有焦慮的感覺“I’vealwaysbeenthisway”我ㄧ直都是這個樣子28Copyright2005JohnWiley&Sons,NYSchoolPhobia

懼學症Twotypes二種類型Separationanxiety分離焦慮Worryaboutparentalsafetywhenseparated當分離時擔心父母安全

Fearofschool對上學害怕Beginslaterinchildhood在兒童期較晚時開始Moresevereandpervasiveavoidance更為嚴重和廣泛性的逃避29Copyright2005JohnWiley&Sons,NYSocialPhobia

懼學症Extremeshynessandwithdrawal極端害羞和退縮Mayexhibitselectivemutism可能呈現選擇性緘默症的症狀Refusaltospeakinunfamiliarsocialsetting不願意在不熟悉的社會情境中說話Prevalence盛行率1%ofchildrenandadolescents兒童和青少年為百分之ㄧEtiology病因學Overestimationofthreat對威脅的高估Underestimationofcopingability對自我應付能力的低估Poorsocialskills社交技巧不佳30Copyright2005JohnWiley&Sons,NYPTSD

創傷後壓力症候群Exposuretotrauma暴露於創傷Chronicphysicalorsexualabuse長期身體或性虐待Communityviolence社區暴力Naturaldisasters自然災害Symptomcategories症狀種類Flashbacks,nightmares,intrusivethoughts經驗瞬間再現,惡夢,侵入性思考Avoidance逃避Hyperarousalandvigilance過度容易被激發和警覺Etiology病因學Preexistinganxiety原先即存在焦慮Familystressandcopingstyles家庭壓力和應對方式Parentalresponsetotrauma父母親對創傷的反應31Copyright2005JohnWiley&Sons,NYTreatmentofAnxietyDisordersinChildhoodandAdolescence

在兒童期和青少年期焦慮疾患的治療Exposuretofearedobject暴露於所害怕的物體Rewardapproachbehavior獎賞接近的行為Modeling示範CBTKendall’sCopingCatprogramCognitiverestructuring認知重組Psychoeducation心理教育Modelingandexposure示範和暴露Skillstraining技巧訓練Relapseprevention再發預防Includefamilyintreatment治療包括家人32Copyright2005JohnWiley&Sons,NYLearningDisability

學習障礙Evidenceofinadequatedevelopmentinaspecificareaofacademic,language,speechormotorskills在學業、語言、說話或運動技能領域有不適當發展的證據e.g.,arithmeticorreading例如：數學或閱讀學習障礙Notduetomentalretardation,autism,physicaldisorderorlackofeducationalopportunity不是由於智能遲緩,生理疾病或缺乏教育機會所造成Individualusuallyaverageoraboveaverageintelligence

個體通常有平均或高於平均的智力33Copyright2005JohnWiley&Sons,NYLearningDisability

學習障礙DSM-IV-TRcategories在DSM-IV-TR中的類別Learningdisorders學習疾患Communicationdisorders溝通疾患Motorskillsdisorder運動技能疾患Oftenidentifiedandtreatedinschool通常在學校中被辨認和治療Readingdisordersmorecommoninboys在男孩閱讀疾患更為普遍34Copyright2005JohnWiley&Sons,NYLearningDisorders

學習障礙Readingdisorder(dyslexia)閱讀疾患(失讀症)Problemswithwordrecognitionandreadingcomprehension對於字的辨認和閱讀理解有問題Disorderofwrittenexpression文字表達疾患Problemswritingincludingspelling,grammar,andpunctuationerrors文字寫作問題包括：拼字,文法和標點符號的錯誤Mathematicsdisorder數學疾患Problemscounting,rememberingarithmeticfacts,andalignmentofnumbersincolumns在算術,記住數學事實和欄位數字的排列上有問題35Copyright2005JohnWiley&Sons,NYCommunicationDisorders

溝通疾患ExpressiveLanguagedisorder語言表達疾患Difficultyexpressingselfinverbalspeech有困難以口語表達自己Speaksinshortphrases說簡短的片語Forgetswordmeanings忘記字義Phonologicaldisorder音韻疾患Vocabularyadequatebutdifficultyarticulatingspeechsounds有足夠字彙但有困難清晰的發音Completerecoverycommonwithspeechtherapy經由語言治療普遍可以完全恢復Stuttering口吃Frequentrepetitionsorprolongationsofsounds經常語音重複或拖長Longpausesbetweenwords在字的中間有較長的暫停Repeatingwords重複字詞Bodytwitchingandblinking身體痙孿和眨眼80%recoverbyage16在年齡十六歲時，有八成會恢復36Copyright2005JohnWiley&Sons,NYMotorSkillsDisorder

運動技能疾患Alsoknownasdevelopmentalcoordinationdisorder也被稱為是發展性運動協調疾患Markedimpairmentinmotorcoordination動作協調上有明顯的受損e.g.,difficultytyingshoes,writing,catchingaball例如：有困難綁鞋帶、寫作和接住球37Copyright2005JohnWiley&Sons,NYEtiologyofLearningDisabilities:Dyslexia

學習障礙的病因學：失讀症Perceptualdeficits知覺缺陷Mirrorimageorreversalofletters鏡像或字母的顛倒Littlesupportforthishypothesis對於此假設獲得較少支持Geneticfactors遺傳因素Evidencefromfamilyandtwinstudies來自家庭和雙生子研究的相關證據Problemsinlanguageprocessing在語言處理上有問題Speechperception語音知覺Difficultyrecognizingrhymeandalliteration有困難辨認韻律和頭韻Problemsnamingfamiliarobjectsrapidly有困難快速的說出熟悉物體的名字Delayslearningsyntacticrules學習句法規則的延遲Deficientphonologicalawareness

語音覺察有缺陷Inadequatelefttemporo-parietal-occipitalfunctioning不良的左顳-頂-枕葉功能38Copyright2005JohnWiley&Sons,NYTreatmentofLearningDisabilities

學習障礙的治療Readingandwritingdisorders閱讀和書寫文字疾患Multisensoryinstructioninlistening,speaking,andwritingskills聽,說,和寫的技巧的多重感官教導Readinessskillsinyoungerchildrenaspreparationforlearningtoread幼小小孩準備就緒技巧作為學習閱讀的準備Phonicsinstruction語音的教導Communicationdisorders溝通疾患FastForWordInvolvescomputergamesandaudiotapesthatslowspeechsounds包括電腦遊戲和語音較慢的錄音帶39Copyright2005JohnWiley&Sons,NYMentalRetardation

智能不足Significantlybelowaverageintellectualfunctioning智力功能顯著低於平均IQlessthan70智商少於七十Deficitsinadaptivefunctioning適應功能的缺陷Self-care,communication,homeliving,decisionmaking,etc.自我照顧,溝通,家居生活,做決定等等Onsetbeforeage18在十八歲前初發Mostprofessionalsfocusonstrengthsofindividualtoassessabilitytofunction多數專家會強調個案的優勢以評估其功能40Copyright2005JohnWiley&Sons,NYTable14.3SampleItemsfromVinelandAdaptiveBehaviorScales

來自Vineland適應行為量表的例題41Copyright2005JohnWiley&Sons,NYTable14.4DSM-IV-TRCategoriesofMentalRetardation

智能不足在DSM-IV-TR的分類42Copyright2005JohnWiley&Sons,NYTable14.5AAMRDefinitionof

MentalRetardation

美國智能不足學會對智能不足的定義43Copyright2005JohnWiley&Sons,NYEtiologyofMentalRetardation:NeurologicalFactors

智能不足的病因學：神經學因素Down’ssyndrome唐氏症Chromosomaltrisomy染色體21有三條(trisomy21)47insteadof46chromosomes有47個染色體而非23對FragileXsyndrome脆性X症候群MutationinthefMRIgeneontheXchromosome在X染色體產生I基因的突變Recessive-genedisease隱性基因疾病Phenylketonuria(PKU)苯酮尿症Maternalinfectiousdisease,especiallyduring1sttrimester母親得到傳染性疾病,特別是在懷孕期的前三個月間HIV,rubella,syphilis愛滋病毒,德國麻疹,梅毒Encephalitis腦膜炎Malnutrition營養不良Braininjuriesfromfallsorautoaccidents跌倒或車禍所導致的大腦受傷Leadormercurypoisoning鉛或汞中毒44Copyright2005JohnWiley&Sons,NYTreatmentofMentalRetardation

智能不足的治療Residentialtreatment住宿治療Smalltomediumsizedcommunityresidences小到中等大小的社區住處Behavioraltreatments行為治療Language,social,andmotorskillstraining語言,社會和動作技巧訓練Methodofsuccessiveapproximationtoteachbasicself-careskillsinseverelyretarded用逐步漸近的方法來教導重度智能障礙的自我照顧技巧e.g.,holdingaspoon,toileting例如：握住湯匙,如廁Cognitivetreatments認知治療Problem-solvingstrategies問題解決策略Computerassistedinstruction電腦輔助教學45Copyright2005JohnWiley&Sons,NYPervasiveDevelopmentalDisorders

廣泛性發展疾患AutisticDisorder自閉性疾患Rett’sDisorderRett氏疾患Childhooddisintegrativedisorder兒童期崩解性疾患Asperger’sdisorder亞斯伯格症46Copyright2005JohnWiley&Sons,NYAutisticDisorder

自閉性疾患Kanner’s(1943)autistic

aloneness在1943年Kanner首度提出自閉一詞Impairmentsinsocialinteractions社會互動的受損Deficientuseofnonverbalbehaviors使用非語言行為的障礙Poorlydevelopedpeerrelationships不良發展的同儕關係Lackofsocialoremotionalreciprocity缺乏社交性或情緒上的相互反應Impairmentsincommunication溝通上的受損Lackofspokenlanguage缺乏口說語言Difficultyinitiatingorsustainingconve