教师在儿童抑郁症处理过程中的作用

,教师在儿童抑郁症处理过程中的作用A Teachers Role in Treatment of Childhood Depression,关于童年抑郁的教师须知,Until recently, the very existence of depression in children was questioned. Today, it is estimated that 20 percent of the school-age population manifests some symptoms of depression 直到晚近，儿童抑郁究竟是否存在仍然是个问题。但是如今据估计有20%的学龄儿童表现出某些抑郁症状。,The “Who” of Childhood Depression “哪些人”患儿童抑郁症,Korup (1985) found that 10 percent of a sample of 226 six- to twelve-year-old students exhibited symptoms of depression. Leftkowitz and Tesiny (1985), in a study of 3,020 elementary school students, reported a 5.2 per-cent prevalence, which is consistent with the average lifetime prevalence suggested by Robins et al. (1984). Using the Beck Depression Inventory, Sullivan and Engin (1986) reported that 26 percent of the tenth- and eleventh-grade students in their sample scored within the moderately depressed range, and 6 percent within the severely depressed range. In a classroom of thirty students, a teacher may anticipate that one or two students will exhibit symptoms of depression.,The “Who” of Childhood Depression “哪些人”患儿童抑郁症,“哪些人”患儿童抑郁症Korup (1985)发现，226名6-12岁孩子组成的样本中有10%的人呈现出抑郁症状。Leftkowitz 和Tesiny (1985), 在研究3,020 小学生时发现有5.2%的孩子有抑郁症。这与Robins 等人(1984)报告的平均终生发病率相一致。Sullivan and Engin (1986)等人利用Beck 量表发现26%10-11年级的学生有轻中度抑郁，6%有重度抑郁。在一个30人的教室里，教师可以预期有1-2人会呈现抑郁症状。,The What of Childhood Depression儿童抑郁症有什么表现,The Diagnostic and Statistical Manual for Mental Disorders (American Psychiatric Association 1979) states that the primary symptom of depression is a dysphoric mood (a loss of interest or pleasure in almost all daily activities). For the diagnosis of depression, a student must exhibit at least four of the following symptoms for a minimum of two weeks: change in appetite or weight, sleep disturbance, psychomotor agitation or retardation, loss of interest in usual activities, loss of energy, feelings of worthlessness or excessive guilt, difficulty concentrating, and thoughts of death or suicide.,The “What” of Childhood Depression儿童抑郁症有什么表现,精神障碍的诊断与统计手册告诉我们，抑郁症的基本症状是“抑郁心境”（dysphoric mood. depression: a state of feeling acutely hopeless, uncomfortable, and unhappy ）（a loss of interest or pleasure in almost all daily activities对几乎所有的日常活动都失去了兴趣或愉悦）。为了确定一个抑郁症的诊断，以下症状中的至少4个必须持续至少2周：胃口或体重的改变，睡眠的障碍，精神运动的易激惹或迟钝，对日常活动兴趣的丧失，精力的丧失，无价值感或过份的负罪感，注意力难以集中，死亡或自杀的念头。,The What of Childhood Depression儿童抑郁症有什么表现,Cantwell (1983a) describes four historical schools of thought concerning depression in children. The first suggested that depression, such as that found in adults, did not occur among children. The second suggested that depression existed in children, characterized by symptoms not apparent in adults. The third school of thought described masked depression or depressive equivalents among children. Depression was perceived to assume a different form in children. Children were thought to demonstrate boredom, restlessness, fatigue, difficulties in concentrating, and aggression, rather than the adult behaviors of sleep disturbance, self-reproach, guilt, and loss (Garfinkel and Golumbek 1974). Cantwell indicates, however, that the behaviors that supposedly masked childhood depression are found among adults as well. To alert professionals, the childs depression was not masked.,The What of Childhood Depression儿童抑郁症有什么表现,Cantwell (1983a) 描述了历史上4个关于儿童抑郁症的学派。1，主张在成人中看到的抑郁症，在儿童中是没有的。2，认为儿童中存在着抑郁症，但是其特有的症状在成人期表现不明显。3，描述了儿童中“面具性的抑郁”或“抑郁的等价物。”在这个学派视野中，儿童抑郁症采取了与成人不同的形式。他们认为儿童会表现出厌倦、躁动，疲乏，注意力分散和攻击性（boredom, restlessness, fatigue, difficulties in concentrating, and aggression），而不是象成人那样表现出睡眠反常，自我责备，负罪感和丧失感(Garfinkel and Golumbek 1974)。然而，Cantwell 指出，那些被认为给儿童抑郁带上面具的行为在成人中也能看到，为了惊醒专业人员，他认为儿童抑郁症并没有被“面具化。”,The What of Childhood Depression儿童抑郁症有什么表现,The most recent school of thought suggests that depression in children has a clinical pattern analogous to that in adults. Though there may be age-specific behaviors among infants, children, and adolescents, the diagnostic criteria for depression remain the same.,The What of Childhood Depression儿童抑郁症有什么表现,4， 最晚近的学派认为，儿童抑郁症具有类似于成人的临床模式。尽管在幼儿，儿童和青少年中会有一些带上年龄特征的行为，但是抑郁症的诊断标准未尝有变。,The What of Childhood Depression儿童抑郁症有什么表现,Childhood depression is usually identified by inter-viewing the parents and the child, and by using behavior rating scales (Cantwell 1983b). There are several considerations for assessing depression among children (Weller, Weller, and Fristad 1984a). The behaviors exhibited by depressed children may be different from those exhibited by adults and may be related to the develop-mental level of the child. Kovacs and Paulaniskus (1984) found that less mature students exhibited greater disruptions in experiencing pleasure and were more self- deprecating. Older children exhibited disobedience, op-positional behavior, and complaints of aches and pains. Herzog and Rathbun (1982) also reported develop-mental influences on symptoms of children who are depressed. They suggested that six- to eight-year-olds exhibited prolonged unhappiness, irritability, and somber affect. Older children exhibited sadness, apathy, helplessness, and irritability.,The What of Childhood Depression儿童抑郁症有什么表现,确珍儿童抑郁症的方法是与父母和孩子面谈，并使用某些行为量表(Cantwell 1983b)。在测评儿童抑郁症时，有几件事情需要考虑。抑郁儿童展现的行为也许不同于抑郁成人所展现的，这些行为也许与儿童的成长水平相关联。Kovacs 和 Paulaniskus (1984) 发现那些不够成熟的学生在高兴的时候会表现出更多的破坏性行为，并且会有更多的自我贬低。年长些的孩子则表现出不服从，对抗，和抱怨疼痛和不舒服。Herzog 和 Rathbun (1982) 报告了成长对于儿童抑郁症症状的影响。他们认为，6-8岁的孩子表现出长时间的的不愉快，易怒，和忧郁的情感（prolonged unhappiness, irritability, and somber affect）。更大些的孩子表现出悲伤，冷漠，无奈和易怒（sadness, apathy, helplessness, and irritability.）。,The What of Childhood Depression儿童抑郁症有什么表现,Weller and associates (1984a) suggest that the range of cognitive and language skills among children of various ages affects their interpretations of questions and responses during assessment. Weller and associates (1984a) and Carlson and Cantwell (1980) suggest that some depressed children demonstrate conduct or behavioral disorders. Depression is identified only after thorough assessment. Describing depression in children is further complicated by the influences of different situations on behavior. Meyer and Hokanson (1985) found considerable situational specificity in self-reports of the behavior of depressed persons. When stressed by intimates, depressed persons were most likely to exhibit sadness. When similar stresses are imposed by strangers, social withdrawal was the most frequent response. In school, behaviors may be influenced by the quality of the relationships with teachers and classmates.,The What of Childhood Depression儿童抑郁症有什么表现,Weller 和他的同事(1984a)认为不同年龄儿童的认知和语言技能影响他们对问题的解释和他们在测评期间的反应。Weller 及其同事(1984a) 以及Carlson 和 Cantwell (1980)指出，某些抑郁的儿童表现出举止或行为的障碍。只有通过彻底的测评，才能确诊抑郁症。由于不同场面对行为的影响，对抑郁的描述就更为复杂了。Meyer 和 Hokanson (1985) 发现明显的场面特殊性对于抑郁当事人的自我报告的影响。当面对亲密者的关切时，抑郁症当事人最有可能展现悲伤。而面对陌生人的类似关切，他们最频繁的反应是社交的退缩。在学校中，他们与教师和同学的关系的性质会影响他们的行为。,The What of Childhood Depression儿童抑郁症有什么表现,Rating scales for child depression, such as the Childrens Depression Inventory (Carlson and Cantwell 1982) and the Hopelessness Scale for Children (Kazdin, Rodgers, and Colbus 1986) are attempts to quantify depression and are usually used clinically (Kovacs 1981). Parent and child reports on clinical instruments have not been found to correlate, although clinical in-struments do distinguish depressed from nondepressed children (Kazdin, French, Unis, and Esveldt-Dawson 1983). Self-report seems to produce the most accurate information, and interviews identify more children with depression than do standard evaluation procedures (Carlson and Cantwell 1980). Self-rating questionnaires may eventually be used as screening instruments in that they can be administered to large numbers of subjects, and are useful in identifying students for more thorough study (Hodgman 1985).,The What of Childhood Depression儿童抑郁症有什么表现,测评量表如Childrens Depression Inventory (Carlson and Cantwell 1982) 以及Hopelessness Scale for Children (Kazdin, Rodgers, and Colbus 1986)。这些量表试图对抑郁症状进行量化，并往往被用于临床。没有发现父母与孩子运用临床工具给出的报告之间有相关性，尽管临床工具确实能区分抑郁与非抑郁(Kazdin, French, Unis, and Esveldt-Dawson 1983)。自我报告似乎能产生最准确的信息，而面谈比标准的评估方法能确认出更多的抑郁儿童(Carlson and Cantwell 1980)。自我测评的问卷也许最终会被当作筛选的工具，因为它们可以用于大数量的被试，并且对于确定需要进一步研究的对象而言，也是很有用的。,The What of Childhood Depression,Teachers may identify several indicators of depression among their students. Korup (1985) found that depressed students had significantly lower grades in effort than students who were not depressed, although most were at grade level in reading and mathematics. Depressed students were unable to work or play alone or with others. Parents reported sleeping problems, physical complaints, and academic difficulties in their children yet were not aware of their childrens social withdrawal, tiredness, depressed feelings, and thoughts of suicide. Peck (1981) suggests that students may act out their depression through substance abuse, running away, petty crimes, and aggressive behaviors.,The What of Childhood Depression,教师可以在他们的学生中找到几种抑郁症的迹象。Korup (1985) 发现，抑郁的学生努力的程度明显比不抑郁的学生低，尽管在阅读和数学方面，他们大部分人的成绩仍然达到平均值。抑郁的学生难以单独或与其他人一起做事或玩乐。家长报告，他们有睡眠问题，会抱怨身体不适，有学习上的困难，但是父母往往没有觉察到他们的孩子有社交的退缩，疲倦，抑郁的情感，以及自杀念头。Peck (1981) 提示我们说，抑郁的学生们也许会通过吸毒，离家出走，小型犯罪和攻击性行为来发泄其抑郁情绪。,The What of Childhood Depression,Peers report that their depressed classmates are unpopular, unhappy, and have problems in school achievement (Leftkowitz and Tesiny 1985). Children of both sexes who score in the lower quartile of reading and intelligence tests are generally at more risk for depression. Symptoms of depression that may be recognized by teachers are summarized in Figure 1.,The What of Childhood Depression,伙伴们报告说，抑郁的同学不受欢迎，不愉快，而且学校的成就也有问题(Leftkowitz and Tesiny 1985)。不管男孩还是女孩，凡是阅读和智商测试成绩在下部的1/4者，一般来说都具有更高的抑郁的风险。表1总结了可以被教师察觉到的抑郁症状。,The What of Childhood Depression,表1.教师可以观察到的童年抑郁的症状学业的征侯 情感的征侯学校表现下降 低自尊失去了参加活动的兴趣 易激惹努力程度降低，成绩仍属平均 表达无价值或负罪感成绩问题 不受欢迎，疏远朋友 悲伤，不快乐 总以为自己有病 社交活动减少,The What of Childhood Depression,表1.教师可以观察到的童年抑郁的症状 社交/行为征侯 躯体的征侯多动 疲倦难以单独做事或玩乐 年幼学生尿床或大便失禁年幼的学生会有过度活动 精神运动的燥动或迟缓无精打采 睡眠问题攻击，撒谎，偷窃 年长学生的躁动 破坏性行为 体重减轻或增加身体不适的抱怨 胃口改变年长学生的躁动 精力丧失更年幼的学生的恐怖和/或分离,The What of Childhood Depression,表1.教师可以观察到的童年抑郁的症状 认知的征侯自杀念头的表达无法集中注意力,The Why of Childhood Depression 儿童抑郁症的“为什么”,Current knowledge of the sources of childhood depression is inconclusive (Epstein and Cullinan 1986). Weller, Weller, and Fristad (1984b) suggest several interpretations of childhood depression. The psychoanalytic model interprets depression as the reaction to the loss of a loved one. The sociological model interprets depression as the result of a social structure that deprives the individual of desirable social roles. In addition, there may be genetic and biochemical explanations of depression.,The Why of Childhood Depression 儿童抑郁症的“为什么”,当前关于童年抑郁的根源的知识仍然不是结论性的(Epstein and Cullinan 1986)。Weller, Weller, 和 Fristad (1984b) 提示了关于童年抑郁的几种解释。精神分析模式将抑郁解释为由于亲爱者的丧失而产生的反应。社会学模式将抑郁解释为社会结构剥夺了个人所向往的社会角色的结果。此外，也许还有抑郁症的遗传学和生物化学方面的解释。,The Why of Childhood Depression 儿童抑郁症的“为什么”,Four of the models that Weller, Weller, and Fristad (1984b) suggest seem more applicable among teachers. The behavior reinforcement model suggests that depressive behaviors are elicited by inadequate or insufficient positive reinforcement. Petti (1983) suggests that appropriate behaviors decrease through a lack of reinforcement. Powerlessness is produced as a response to the lack of reinforcement and the failure to elicit appropriate behaviors. Depressive behaviors are developed, reinforced, and maintained by the limited reinforcement in the environment.,The Why of Childhood Depression 儿童抑郁症的“为什么”,Weller, Weller, 和 Fristad (1984b) 所提示的4种模式更适用于教师。行为强化模式提示说，抑郁行为是不适当或不充分的正强化所引起的。Petti (1983) 提示说，由于缺乏强化，适当的行为就会减少。正强化缺乏所引起的反应是势孤力单的感觉，而且会疏于给出适当的行为。由于环境中只有很少的正强化，抑郁的行为就产生出来，被强化并被维持下去。,The Why of Childhood Depression 儿童抑郁症的“为什么”,A second interpretation applicable in educational settings is that of learned helplessness. The depressed student perceives behavior as independent of reinforcement, leading to a sense of hopelessness. The student develops a cognitive style of attribution that is outside of the self (Petti 1983).,The Why of Childhood Depression 儿童抑郁症的“为什么”,第二种适用于教育情境的解释是习得的无能为力。抑郁的学生感到依靠他的行为是没有办法得到强化的，这就引起了毫无希望的感觉。这样的学生就产生出一种归因的认知风格，认为一切事情都不是他所能控制的(Petti 1983)。,The Why of Childhood Depression 儿童抑郁症的“为什么”,The third model applicable for teachers is that of cognitive distortion, in which negative conceptualizations of ones view of self, world, and the future are the source of the depression. Depressed children demonstrate a negative cognitive set or hopelessness (Petti 1983). Haley, Fine, Marriage, Moretti, and Freeman (1985) found that depressed and distorted cognitions significantly correlate with psychiatric and self-reports of depression.,The Why of Childhood Depression,第三种适用于教师的模式是认知的歪曲。该模式认为，一个人对自己，对世界，以及对未来的消极的观点才是抑郁的源泉。抑郁的儿童展现出一套消极的认知或前途无望的感觉(Petti 1983)。Haley, Fine, Marriage, Moretti, 和 Freeman (1985) 发现，抑郁的和歪曲的认知与抑郁症的精神病学的或自我的报告之间有显著的相关性。,The Why of Childhood Depression,A fourth model of depression that is applicable to schools and teachers involves life stress. In this model, stress and environmental changes that require readjustment are the cause of depression. Nezu and Ronan (1985), in their analysis of 205 undergraduate students, concluded that negative life events can increase coping problems. The degree to which an individual actively copes with these problems is a function of coping ability. Effectively resolving problems decreases the likelihood of experiencing depression.,The Why of Childhood Depression,适用于学校和教师的第四种抑郁症模式涉及到生活压力。根据这个模式，需要重新适应的压力和环境的改变是抑郁症的原因。Nezu 和 Ronan (1985), 根据他们对于205 名大学生的分析得出结论说，消极的生活事件可以引起应对的困难。个体主动应对这些困难的程度就是他们的应对能力的功能。有效解决问题的能力减少了抑郁的可能性。,What Is a Teacher to Do? 教师可以做些什么？,Cantwell (1983c) maintains that several factors must be considered in planning treatment. The teacher, although unable to diagnose and plan the treatment of childhood depression, is invaluable in screening students for further evaluation and cooperating with treatment. Here are some specific activities in which teachers may participate. 1. Assist in the identification of students at risk for depression. Students exhibiting the symptoms described should be referred to the school guidance counselor or social worker. Teachers may be able to assist in initial contacts with parents with whom they have good rapport. Working with children who are depressed is based on an analysis of the strengths and competencies of the child and family with which one could work in developing helping strategies (Cantwell 1983c). Teachers may supply invaluable information to assist in the analysis and development of a treatment plan,What Is a Teacher to Do? 教师可以做些什么？,Cantwell (1983c) 坚持说，在做处理计划时有几个因素必须考虑。教师尽管无法为童年抑郁进行诊断和安排治疗，但是他们在筛查需要进一步评估的学生和在治疗中进行合作这两个方面却具有不可估量的价值。以下是教师可以参与的一些特殊活动。1，帮助确认有抑郁症风险的学生。应该将表现出上述症状的学生转介给学校咨询师或社会工作者。教师可以协助与那些和他们关系较好的父母进行初步接触。对抑郁孩子的帮助建立在对孩子的长处和能力，以及他们的可以与之合作的家庭的分析。教师可以提供非常有价值的信息，以便协助这样的分析和治疗计划的制定。,What Is a Teacher to Do? 教师可以做些什么？,2. Cooperate with medical interventions. Epstein and Cullinan (1986) suggest that medication is one of the most promising interventions with depression. Approximately 75 percent of the depressed individuals taking medication improve with antidepressants. However, un-pleasant and even dangerous side effects such as fatigue, dry mouth, nausea, cardiovascular irregularities, and seizures have been reported. Teachers should keep parents informed of their observations of these symptoms.,What Is a Teacher to Do? 教师可以做些什么？,2，与干预者合作。Epstein 和 Cullinan (1986) 提出服药对于抑郁症是最有希望的干预之一。大约75%的抑郁症个人服用抗抑郁药物后获得了改善。然而，令人不快的甚至危险的副作用也有报道。例如，疲倦，口干，恶心，心血管系统的反常现象，和抽搐。教师应该对这些症状进行持续观察，并随时通告父母。,What Is a Teacher to Do? 教师可以做些什么？,3. Train students in social skills. Poor social skills may maintain depression in students (Epstein and Cul-linan 1986). Social skills training may both prevent and alleviate depression among students. Such training assists students by providing opportunities to model and rehearse the skill. Feedback and contingent social reinforcement for skilled performance and self-management are stressed.3，训练学生的社交技能。不良的社交技能会使学生的抑郁症状维持下去(Epstein and Cul-linan 1986)。社交技能的训练可以预防和缓解学生的抑郁症状。这类训练通过提供示范和预演这些技能的机会来帮助学生。训练中强调对于良好的表现给以反馈和有针对性的社会强化，同时也强调自我管理。,What Is a Teacher to Do? 教师可以做些什么？,4，Employ cognitive therapy techniques or cognitive behavior modification training when appropriate. Cognitive therapy assumes that children who are capable of developing the negative thinking associated with depression are just as capable of changing their thinking through cognitive strategies (Epstein and Cullinan 1986). Teachers can help students monitor their own behavior. They can