儿童期疾患ppt课件

Copyright 2005 John Wiley & Sons, NY,1,PowerPoint Lecture Notes Presentation Disorders of Childhood 兒童期疾患,Copyright 2005 John Wiley & Sons, NY,2,Classification and Diagnosis of Childhood Disorders 兒童期疾患的分類和診斷,Developmental psychopathology 發展的心理病理學 Studies disorders of childhood within the context of normal child development 在正常兒童發展的背景脈絡下研究兒童期的疾患 Externalizing disorders 外化性疾患 Characterized by outward behaviors 以外化性的行為為其特性 Noncompliance, aggressiveness, overactivity, impulsiveness 不服從,攻擊,過動,衝動 More common in boys 在男孩較普遍 Internalizing disorders 內化性疾患 Characterized by inward behaviors 以向化的行為為其特性 Depression, anxiety, social withdrawal 憂鬱,焦慮,社會退縮 More common in girls 在女孩較普遍,Copyright 2005 John Wiley & Sons, NY,3,Table 14.1 Chapters Where Disorders are Discussed That Occur in Both Children and Adults 在兒童和成人身上皆會發生的疾患章節,Copyright 2005 John Wiley & Sons, NY,4,Attention Deficit/Hyperactivity Disorder 注意力不足/過動疾患,Excessive levels of activity 過多的活動 Fidgeting, squirming, running around when inappropriate, incessant talking 不安,扭動,不恰當的走動,不停的說話 Distractability and difficulty concentrating 分心和有困難集中 Makes careless mistakes, cant follow instructions, forgetful 粗心犯錯,不能聽從指令,健忘 Must be severe and persistent 必須嚴重且持續 Present for at least 6 months and cause impairments in functioning 持續至少六個月並產生功能的受損,Copyright 2005 John Wiley & Sons, NY,5,Attention Deficit/Hyperactivity Disorder 注意力不足/過動疾患,Three subcategories in DSM-IV-TR 在DSM-IV-TR中可分為三個亞型： Predominantly inattentive type 主要為不注意型 Predominantly hyperactive-impulsive type 主要為過動-易衝動型 Combined type 複合型 Differential diagnosis 鑑別診斷 ADHD or Conduct Disorder? 注意力不足過動疾患或品性疾患？ ADHD注意力不足過動疾患 More off-task behavior, cognitive & achievement deficits 較多無法達成工作的行為,認知和成就上缺陷 Conduct Disorder 品行疾患 More aggressive, act out in most settings, antisocial parents, family hostility 較多攻擊性, 常出現動作外化行為,反社會性父母,家人敵意,Copyright 2005 John Wiley & Sons, NY,8,Etiology of ADHD 注意力不足過動疾患的病因學,Perinatal and prenatal factors 出生前後和產前因素 Low birth weight 出生體重低 Maternal tobacco and alcohol use 母親吸菸和酒精使用 Environmental toxins 環境毒素 Food additives and sugar not related to ADHD 食品添加物和糖與注意力不足過動疾患沒有相關 Nicotine from maternal smoking 來自母親吸煙所產生尼古丁 May damage dopaminergic system in fetus 可能損害胎兒多巴胺內生性系統,Copyright 2005 John Wiley & Sons, NY,9,Etiology of ADHD 注意力不足過動疾患的病因學,Psychological Factors 心理因素 Ineffective parenting, negative interactions 無效能的親職教育,負向互動 Probably interact with genetic and neurobiological factors 可能和遺傳和神經生物因素產生交互影響 Likely to exacerbate or maintain ADHD behaviors but not cause them 很可能惡化或維持ADHD的行為問題但不會造成此疾患,Copyright 2005 John Wiley & Sons, NY,10,Treatment of ADHD 注意力不足過動疾患的治療,Stimulant medications 興奮劑藥物治療 Reduce disruptive behavior 降低破壞性行為 Improve attention and concentration 改善注意力和專心 Ritalin 利他能 Adderall Concerta Strattera Side effects 副作用 Loss of appetite 失去食慾 Sleep problems 睡眠問題,Copyright 2005 John Wiley & Sons, NY,11,Treatment of ADHD 注意力不足過動疾患的治療,Psychological treatment 心理治療 Operant conditioning 操作制約 Parent training 父母親訓練 Classroom management and teacher training 課堂管理和老師的訓練 Classroom structure 課堂結構 Brief assignments 簡短的作業 Immediate feedback 立即回饋 Task-focused style 聚焦於作業的方式 Breaks for exercise 中間休息以作運動,Copyright 2005 John Wiley & Sons, NY,12,Conduct Disorder (CD) 品行疾患,Pattern of engaging in behaviors that violate social norms, the rights of others, and are often illegal.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 Cruelty towards other people or animals 虐待他人或動物 Lying 說謊 Stealing 偷竊 Vandalism 暴力行為 Often accompanied by lack of remorse and callousness 通常伴隨缺乏憐憫和無情,Copyright 2005 John Wiley & Sons, NY,13,Oppositional Defiant Disorder (ODD) 對立性反抗疾患,ODD behaviors do not meet criteria for CD but child displays pattern of defiant behavior 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 Loses temper 脾氣不佳 Lack of compliance 缺乏服從性 Deliberately aggravates other 故意激怒他人 Hostile, vindictive, spiteful, or touchy 充滿敵意,懷恨,惡意或暴躁的 Blame others for their problems 將自己的行為問題責怪他人 Most often diagnosed in boys but may be as prevalent in girls 通常診斷於男孩但女孩也可能很普遍,Copyright 2005 John Wiley & Sons, NY,14,Conduct Disorder (CD) 品行疾患,Many times first identified by legal authorities 通常會先被法庭發現其問題行為 Juvenile delinquents 青少年罪犯 Substance abuse common普遍有物質濫用 Comorbid with anxiety and depression, especially for girls 與焦慮和憂鬱共病,特別是針對女孩 Prevalence 盛行率 Boys 男孩 4 to 16% 百分比四到十六 Girls 女孩 1.2 to 9% 百分比點二到九,Copyright 2005 John Wiley & Sons, NY,15,Figure 14.1 Arrest Rates Across Ages for Homicide, Forcible Rape, Robber, Aggravated Assault, and Auto Theft 殺人、強暴、搶劫、攻擊、偷車者在各年齡層的逮捕率,Copyright 2005 John Wiley & Sons, NY,16,Conduct Disorder (CD) 品行疾患,Moffitt (1993) two paths 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 Not all aggressive or conduct-disordered boys continue aggressive behavior into adulthood 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 Predictive factors 預測因子 Low verbal IQ 低語文智商 Parent with antisocial personality disorder 父母有反社會人格疾患的問題 Temperament 天生氣質 Dysfunctional parent-child interactions 父母與孩子間不良的互動 Poverty 貧窮 Low social support 低社會支持,Copyright 2005 John Wiley & Sons, NY,17,Figure 14.2 Etiology of Conduct Disorder 品行疾患的病因學,Insert Figure 14.2,品行疾患的病因學,社會,心理,神經生物,品行疾患,Copyright 2005 John Wiley & Sons, NY,18,Etiology of Conduct Disorder (CD) 品行疾患的病因學,Genetic factors 遺傳因素 Heritability likely plays a part 遺傳可能扮演一部分因素 Twin study data show mixed results 雙生子研究資料呈現不一致的結果 Adoption studies focused on criminal behavior, not conduct disorder 領養研究著重在犯罪行為，而非品行疾患的行為問題 Evidence for genetic influence 相關證據支持遺傳影響 Genetics and environment interact (Caspi et al., 2002) 遺傳和環境的交互影響 Abuse as a child PLUS low MAOA activity most likely to develop CD 虐待孩子加上低單胺氧化酶活性很可能發展品行疾患,Copyright 2005 John Wiley & Sons, NY,19,Etiology of Conduct Disorder (CD) 品行疾患的病因學,Neurobiological factors 神經生物因素 Poor verbal skills 語文技巧不佳 Difficulty with executive functioning 執行功能的困難 Low IQ 低智商 Psychological factors 心理因素 Deficient moral development, especially lack of remorse 有缺陷的道德發展,特別是缺乏同情 Modeling and reinforcement of aggressive behavior 攻擊行為的模仿和增強 Harsh and inconsistent parenting 嚴格和不致的教養方式 Lack of parental monitoring 缺乏父母的監控 Cognitive bias (Kenneth Dodge) 認知偏誤 Neutral acts by others perceived as hostile 將他人的中性舉動知覺成有敵意的,Copyright 2005 John Wiley & Sons, NY,20,Figure 14.3 Dodges Cognitive Theory of Aggression Dodge的攻擊認知理論,Insert figure 14.3,將模糊舉動解讀成 有敵意,對他人產生攻擊,他人進行報復,對他人產生更進步攻擊,Copyright 2005 John Wiley & Sons, NY,21,Etiology of Conduct Disorder (CD) 品行疾患的病因學,Peer influence 同儕影響 Acceptance or rejection by peers 被同儕接受或拒絕 Affiliation with deviant peers 與有偏差行為的同儕接近 Sociocultural factors 社會文化因素 Poverty 貧窮 Urban environment 都市的環境,Copyright 2005 John Wiley & Sons, NY,22,Treatment of Conduct Disorder 品行疾患的治療,Family interventions 家人的介入 Parental management training (PMT; Gerald Patterson) 父母親管理訓練 Teach parents to reward prosocial behavior 教導父母獎賞利社會行為 Cognitive therapy 認知治療 Anger-control training 憤怒控制訓練,Copyright 2005 John Wiley & Sons, NY,23,Figure 14.4 Multisystemic Treatment of CD 品行疾患的多系統化治療,Insert Figure 14.4,Copyright 2005 John Wiley & Sons, NY,24,Depression in Children and Adolescents 兒童和青少年的憂鬱,Symptoms common to children, adolescents, and adults 兒童,青少年和成人的共同症狀 Depressed mood 憂鬱心情 Inability to experience pleasure 無法經驗愉快 Fatigue 疲累 Problems concentrating 難以集中注意力 Suicidal ideation 自殺意念,Symptoms specific to children & adolescents 兒童和青少年的特定症狀 Higher rates of suicide attempts and guilt 較高比例的自殺嘗試和罪惡感 Lower rates of 較低比例的 Early morning awakening 早晨易醒 Early morning depression 早晨憂鬱 Loss of appetite 缺乏食慾 Weight loss 體重減少,Copyright 2005 John Wiley & Sons, NY,25,Depression in Children and Adolescents 兒童和青少年的憂鬱,Depression recurrent 憂鬱持續再發 Prevalence 盛行率 1% of preschoolers 學齡前兒童為百分之 2 3% of school age children 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 2x that of boys 比男孩高於兩倍,Copyright 2005 John Wiley & Sons, NY,26,Etiology of Depression in Children and Adolescents 兒童和青少年憂鬱的病因學,Genetic factors 遺傳因素 Family and relationship factors 家庭和人際關係因素 A parent who is depressed 父母有方是憂鬱的 Cold and hostile family interactions 冷漠和敵意的家庭互動 Poor social skills 社交技巧不佳 Impaired relationships with peers and siblings 和同儕和兄弟姐妹有不良的關係 Parental criticism 父母的批評,Copyright 2005 John Wiley & Sons, NY,27,Treatment of Depression in Children and Adolescents 兒童和青少年憂鬱的治療,Much less research on childhood depression 對於兒童憂鬱較少研究 Medications 藥物治療 SSRIs more effective than tricyclics 選擇性血清素抑制劑較三環抗鬱劑來得有效 Concerns about increased risk of suicide attempts 自殺嘗試的風險增加 CBT plus Prozac more effective than either alone 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 Prozac alone more effective than CBT alone 單獨使用百憂解比單獨使用認知行為治療更為有效 Interpersonal psychotherapy (IPT) 人際關係心理治療 CBT in school setting 學校環境的認知行為治療 Treatment of depressed parent 憂鬱父母的治療,Copyright 2005 John Wiley & Sons, NY,28,Anxiety in Children and Adolescents 兒童和青少年的焦慮,Fears and worries common in childhood 在兒童期害怕和憂慮很普遍 Anxiety disorder 焦慮疾患 More severe and persistent worry 更為嚴重和持續性的憂慮 Must interfere with functioning 必須妨害日常生活功能 Most childhood fears disappear but adults with anxiety disorders report feeling anxious as children 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 “Ive always been this way” 我直都是這個樣子,Copyright 2005 John Wiley & Sons, NY,29,School Phobia 懼學症,Two types 二種類型 Separation anxiety 分離焦慮 Worry about parental safety when separated 當分離時擔心父母安全 Fear of school 對上學害怕 Begins later in childhood 在兒童期較晚時開始 More severe and pervasive avoidance 更為嚴重和廣泛性的逃避,Copyright 2005 John Wiley & Sons, NY,30,Social Phobia 懼學症,Extreme shyness and withdrawal 極端害羞和退縮 May exhibit selective mutism 可能呈現選擇性緘默症的症狀 Refusal to speak in unfamiliar social setting 不願意在不熟悉的社會情境中說話 Prevalence 盛行率 1% of children and adolescents 兒童和青少年為百分之 Etiology 病因學 Overestimation of threat 對威脅的高估 Underestimation of coping ability 對自我應付能力的低估 Poor social skills 社交技巧不佳,Copyright 2005 John Wiley & Sons, NY,31,PTSD 創傷後壓力症候群,Exposure to trauma 暴露於創傷 Chronic physical or sexual abuse 長期身體或性虐待 Community violence 社區暴力 Natural disasters 自然災害 Symptom categories 症狀種類 Flashbacks, nightmares, intrusive thoughts 經驗瞬間再現,惡夢,侵入性思考 Avoidance 逃避 Hyperarousal and vigilance 過度容易被激發和警覺 Etiology 病因學 Preexisting anxiety 原先即存在焦慮 Family stress and coping styles 家庭壓力和應對方式 Parental response to trauma 父母親對創傷的反應,Copyright 2005 John Wiley & Sons, NY,32,Treatment of Anxiety Disorders in Childhood and Adolescence 在兒童期和青少年期焦慮疾患的治療,Exposure to feared object 暴露於所害怕的物體 Reward approach behavior 獎賞接近的行為 Modeling 示範 CBT Kendalls Coping Cat program Cognitive restructuring 認知重組 Psychoeducation 心理教育 Modeling and exposure 示範和暴露 Skills training 技巧訓練 Relapse prevention 再發預防 Include family in treatment 治療包括家人,Copyright 2005 John Wiley & Sons, NY,33,Learning Disability 學習障礙,Evidence of inadequate development in a specific area of academic, language, speech or motor skills 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., arithmetic or reading 例如：數學或閱讀學習障礙 Not due to mental retardation, autism, physical disorder or lack of educational opportunity 不是由於智能遲緩,生理疾病或缺乏教育機會所造成 Individual usually average or above average intelligence 個體通常有平均或高於平均的智力,Copyright 2005 John Wiley & Sons, NY,34,Learning Disability 學習障礙,DSM-IV-TR categories 在DSM-IV-TR中的類別 Learning disorders 學習疾患 Communication disorders 溝通疾患 Motor skills disorder 運動技能疾患 Often identified and treated in school 通常在學校中被辨認和治療 Reading disorders more common in boys 在男孩閱讀疾患更為普遍,Copyright 2005 John Wiley & Sons, NY,35,Learning Disorders 學習障礙,Reading disorder (dyslexia) 閱讀疾患(失讀症) Problems with word recognition and reading comprehension對於字的辨認和閱讀理解有問題 Disorder of written expression 文字表達疾患 Problems writing including spelling, grammar, and punctuation errors 文字寫作問題包括：拼字,文法和標點符號的錯誤 Mathematics disorder 數學疾患 Problems counting, remembering arithmetic facts, and alignment of numbers in columns 在算術,記住數學事實和欄位數字的排列上有問題,Copyright 2005 John Wiley & Sons, NY,36,Communication Disorders 溝通疾患,Expressive Language disorder 語言表達疾患 Difficulty expressing self in verbal speech 有困難以口語表達自己 Speaks in short phrases 說簡短的片語 Forgets word meanings 忘記字義 Phonological disorder 音韻疾患 Vocabulary adequate but difficulty articulating speech sounds 有足夠字彙但有困難清晰的發音 Complete recovery common with speech therapy 經由語言治療普遍可以完全恢復 Stuttering 口吃 Frequent repetitions or prolongations of sounds 經常語音重複或拖長 Long pauses between words 在字的中間有較長的暫停 Repeating words 重複字詞 Body twitching and blinking 身體痙孿和眨眼 80% recover by age 16 在年齡十六歲時，有八成會恢復,Copyright 2005 John Wiley & Sons, NY,37,Motor Skills Disorder 運動技能疾患,Also known as developmental coordination disorder 也被稱為是發展性運動協調疾患 Marked impairment in motor coordination 動作協調上有明顯的受損 e.g., difficulty tying shoes, writing, catching a ball 例如：有困難綁鞋帶、寫作和接住球,Copyright 2005 John Wiley & Sons, NY,38,Etiology of Learning Disabilities: Dyslexia 學習障礙的病因學：失讀症,Perceptual deficits 知覺缺陷 Mirror image or reversal of letters 鏡像或字母的顛倒 Little support for this hypothesis 對於此假設獲得較少支持 Genetic factors 遺傳因素 Evidence from family and twin studies 來自家庭和雙生子研究的相關證據 Problems in language processing 在語言處理上有問題 Speech perception 語音知覺 Difficulty recognizing rhyme and alliteration 有困難辨認韻律和頭韻 Problems naming familiar objects rapidly 有困難快速的說出熟悉物體的名字 Delays learning syntactic rules 學習句法規則的延遲 Deficient phonological awareness 語音覺察有缺陷 Inadequate left temporo-parietal-occipital functioning 不良的左顳-頂-枕葉功能,Copyright 2005 John Wiley & Sons, NY,39,Treatment of Learning Disabilities 學習障礙的治療,Reading and writing disorders 閱讀和書寫文字疾患 Multisensory instruction in listening, speaking, and writing skills 聽,說,和寫的技巧的多重感官教導 Readiness skills in younger children as preparation for learning to read 幼小小孩準備就緒技巧作為學習閱讀的準備 Phonics instruction 語音的教導 Communication disorders 溝通疾患 Fast ForWord Involves computer games and audiotapes that slow speech sounds 包括電腦遊戲和語音較慢的錄音帶,Copyright 2005 John Wiley & Sons, NY,40,Mental Retardation 智能不足,Significantly below average intellectual functioning智力功能顯著低於平均 IQ less than 70 智商少於七十 Deficits in adaptive functioning 適應功能的缺陷 Self-care, communication, home living, decision making, etc. 自我照顧,溝通,家居生活,做決定等等 Onset before age 18 在十八歲前初發 Most professionals focus on strengths of individual to assess ability to function 多數專家會強調個案的優勢以評估其功能,Copyright 2005 John Wiley & Sons, NY,41,Table 14.3 Sample Items from Vineland Adaptive Behavior Scales 來自Vineland適應行為量表的例題,Copyright 2005 John Wiley & Sons, NY,42,Table 14.4 DSM-IV-TR Categories of Mental Retardation 智能不足在DSM-IV-TR的分類,Copyright 2005 John Wiley & Sons, NY,43,Table 14.5 AAMR Definition of Mental Retardation 美國智能不足學會對智能不足的定義,Copyright 2005 John Wiley & Sons, NY,44,Etiology of Mental Retardation: Neurological Factors 智能不足的病因學：神經學因素,Downs syndrome 唐氏症 Chromosomal trisomy 染色體21有三條 (trisomy 21) 47 instead of 46 chromosomes 有47個染色體而非23對 Fragile X syndrome 脆性X症候群 Mutation in the fMRI gene on the X chromosome 在X染色體產生I基因的突變 Recessive-gene disease 隱性基因疾病 Phenylketonuria (PKU) 苯酮尿症 Maternal infectious disease, especially during 1st trimester 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 Brain injuries from falls or auto accidents 跌倒或車禍所導致的大腦受傷 Lead or mercury poisoning 鉛或汞中毒,Copyright 2005 John Wiley & Sons, NY,45,Treatment of Mental Retardation 智能不足的治療,Residential treatment 住宿治療 Small to medium sized community residences 小到中等大小的社區住處 Behavioral treatments 行為治療 Language, social, and motor skills training 語言,社會和動作技巧訓練 Method of successive approximation to teach basic self-care skills in severely retarded 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., holding a spoon, toileting 例如：握住湯匙,如廁 Cognitive treatments 認知治療 Problem-solving strategies 問題解決策略 Computer assisted instruction 電腦輔助教學,Copyright 2005 John Wiley & Sons, NY,46,Pervasive Developmental Disorders 廣泛性發展疾患,Autistic Disorder 自閉性疾患 Retts Disorder Rett氏疾患 Childhood disintegrative disorder 兒童期崩解性疾患 Aspergers disorder 亞斯伯格症,Copyright 2005 John Wiley & Sons, NY,47,Autistic Disorder 自閉性疾患,Kanners (1943) autistic aloneness 在1943年Kanner首度提出自閉一詞 Impairments in social interactions 社會互動的受損 Deficient use of nonverbal behaviors 使用非語言行為的障礙 Poorly developed peer relationships 不良發展的同儕關係 Lack of social or emotional reciprocity 缺乏社交性或情緒上的相互反應 Impairments in communication 溝通上的受損 Lack of spoken language 缺乏口說語言 Difficulty initiating or sustaining conversation 有困難引發或維持對話 Repetitious or idiosyncratic language 重覆或使用特異的語言 Echolalia 語言模仿 Pronou