兒科學教學課件：注意力缺陷多動障礙

1Attention-deficit/

HyperactivityDisorder

(ADHD)注意力缺陷多動障礙2DefinitionADHDischaracterizedbyinattention,includingincreaseddistractibility注意力分散

anddifficultysustaining【持續(xù)的】attentionpoorimpulsecontrolanddecreasedself-inhibitorycapacity【自制能力】motoroveractivityandmotorrestlessness

注意力不集中【核心】，行為沖動，活動過度3EpidemiologyprevalenceofADHDacrosstheglobe:5-10%ofschool-agedchildren2-6%ofadolescent2%ofadults4ETIOLOGYGeneticfactorscandidategenes,eg:DAT1,DRD4Environmentfactorsbirthcomplicationsmaternalsmokingandalcoholuseduringpregnancyprenatalorpostnatalexposuretolead…Psychosocialfamily5PathogenesisAbnormalbrainstructuresarelinkedtoanincreasedriskofADHDdopaminehypothesis假設whichpostulatesthatdisturbancesinthedopaminesystemmayberelatedtotheonsetofADHD.多巴胺輸送因子DAT1和多巴胺D1受體變異，失去對多巴胺的敏感性。6ClinicalmanifestationsHyperactivity

活動過度根本停不下來7SymptomsofHyperactivityFidgetswithhandsorfeetorsquirmsinseatLeavesseatinclassroomorinothersituationinwhichremainingseatedisexpectedRunsorclimbsexcessivelywheninappropriateHasdifficultyplayingorengaginginleisureactivitiesquietlyAlwaysonthegooractasifdrivenbyamotorOftentalksexcessivelyInadolescence,mayexhibitfeelingofrestlessness8Impulsivity行為沖動，不計后果Clinicalmanifestations9SymptomsofImpulsivityBlurtsoutanswersbeforequestionshavebeencompletedHasdifficultywaitinginturnInterruptsorintrudesonothers(forexamplebuttsintoconversationsorgames)10ClinicalmanifestationsInattention注意力不集中【核心癥狀】11SymptomsofInattentionFailstopaycloseattentiontodetailsormakescarelessmistakesHasdifficultymaintainingattentionintasksorplayactivitiesDoesnotseemtolistenwhenspokentodirectlyDoesnotfollowdirectionsandfailstocompleteschoolwork,chores,or,inadolescents,onthejobdutiesHasdifficultyorganizingtasksoractivitiesAvoidsordisliketaskthatrequiresustainedmentaleffortLossesthingsnecessaryfortaskoractivitiesEasilydistractedOftenforgetfulindailyactivities12ClinicalmanifestationsODD40%Mooddisorders38%CD14%TICs11%ADHD31%comorbidity伴隨疾病13SUBTYPESOFADHD分類1.Predominantly主要的hyperactive/impulsivetype多動沖動為主型Achildmusthavesixormoresymptomsofhyperactivity/impulsivity2.Predominantlyinattentivetype注意力缺陷為主型Achildmustdisplaysixormoresymptomsofinattention3.Combinedtype混合型Achildmustshowsixormoresymptomsbothofinattentionandhyperactivity-impulsivity14DiagnosticEvaluation診斷評估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社會心理治療theparentsandchildshouldbeeducatedTheclinicianshouldsetgoalsforthefamilytoimprovethechild’sinterpersonalrelationships,developstudyskills,anddecreasedisruptivebehaviors.20ManagementBehaviorallyOrientedTreatments行為導向療法Recommended1stlinetreatmentisevidence-basedparent-and/orteacher-administeredbeha