Attention Deficit / Hyperactive Disorder (ADHD) 注意力缺損過動症

「注意力缺失/過動疾患 Attention-Deficit／Hyperactivity Disorder」 (1) 列6/9項注意力不集中(Inattention)症狀， (2) 列6/9項過動及衝動(Hyperactivity-Impulsivity)症狀， 注意力不足為主 活動量及衝動為主 同時合併以上三種特性 且症狀持續出現至少6個月， 致足以達到適應不良且造成與其應有的發展程度不相符合。

一、注意力不集中 無法注意到小細節或因粗心大意使學校功課、工作或其他活動發生錯誤。 在工作或遊戲活動中無法持續維持注意力。 別人說話時似乎沒在聽。 無法完成老師、家長或他人交辦的事務，包括學校課業、家事零 工、或工作場所的職責（並非由於對抗行為或不了解指示）。  缺乏組織能力。  常逃避、不喜歡或拒絕參與需持續使用腦力的工作；如：工作或家庭作業。 容易遺失或忘了工作或遊戲所須的東西；如：玩具、鉛筆、書等。 容易被外界刺激所吸引。 容易忘記每日常規活動，需大人時常提醒。

二、過動及衝動 (過動) (衝動) 在坐位上無法安靜地坐著，身體動來動去。 在課堂中或其它須乖乖坐好的場合，時常離席、坐不住。 在教室或活動場合中不適當地跑、跳及爬高等（在青少年或成人可僅限於主觀感覺到不能安靜）。 無法安靜地參與遊戲及休閒活動。 經常處於活躍狀態，或常像「馬達推動」般四處活動。 經常說話過多。 (衝動) 問題尚未問完前，便搶先答題。 不能輪流等待 (在需輪流的地方，無法耐心地等待)。 常中斷或干擾其他人 (如：貿然插嘴或打斷別人的遊戲)。

ADHD診斷類型 三亞型 Inattentive type 注意力不集中型 Hyperactive impulsive 過動衝動型 Combined type 結合型 (1+2)

注意力缺失/過動疾患 流行率及人口區域表現 Based on Polanczyk literature search, The ADHD/HD worldwide-pooled prevalence was 5.29%. Male has a higher prevalence at 10%, female has 4 to 5%. The prevalence in Asia was about 4 – 5%. Objective: The worldwide prevalence estimates of attention deficit hyperactivity disorder (ADHD)/hyperkinetic disorder (HD) are highly heterogeneous. Presently, the reasons for this discrepancy remain poorly understood. The purpose of this study was to determine the possible causes of the varied worldwide estimates of the disorder and to compute its worldwide-pooled prevalence. Method: The authors searched MEDLINE and PsycINFO databases from January 1978 to December 2005 and reviewed textbooks and reference lists of the studies selected. Authors of relevant articles from North America, South America, Europe, Africa, Asia, Oceania, and the Middle East and ADHD/HD experts were contacted. Surveys were included if they reported point prevalence of ADHD/HD for subjects 18 years of age or younger from the general population or schools according to DSM or ICD criteria. Results: The literature search generated 9,105 records, and 303 full-text articles were reviewed. One hundred and two studies comprising 171,756 subjects from all world regions were included. The ADHD/HD worldwide-pooled prevalence was 5.29%. This estimate was associated with significant variability. In the multivariate metaregression model, diagnostic criteria, source of information, requirement of impairment for diagnosis, and geographic origin of the studies were significantly associated with ADHD/HD prevalence rates. Geographic location was associated with significant variability only between estimates from North America and both Africa and the Middle East. No significant differences were found between Europe and North America. Conclusions: Our findings suggest that geographic location plays a limited role in the reasons for the large variability of ADHD/HD prevalence estimates worldwide. Instead, this variability seems to be explained primarily by the methodological characteristics of studies. 5.3%, 102 studies, 171,756 children. Africa 8.5%, South America 11.8%, Asia 4.0%, Europe 4.6%, North America 6.2% Polanczyk et al. The Worldwide Prevalence of ADHD: A Systematic Review and Metaregression Analysis. Am J Psychiatry 2007; 164:942–948.

流行病學 高淑芬 (2004): 7.5-3.8% in G7-9 國中學生 Hou (2003): 6.4% 國小學童 Tzang (2002): 8.4-11.7% 國小學童 趙家琛 (1998): 7.5-9% 小三 四國小男童 Leung (1996): 8.9% 香港學童 6-9% US 5-12 y/o children, 60-80% functionally impairing symptoms into adolescence and 50% into adulthood. Pliszka 2007 National comorbidity survey, 3199 adults (19-44) 4.4%. Kessler 2006

社會及情緒困擾 8

ADHD and the Impairment of Social and Emotional Behaviors Strengths and Difficulties Questionnaire, based on the 2003 National Health Information Survey, USA, Strine et al., 2006, Preventing Chronic disease, http://www.cdc.gov/pcd/issues/2006/apr/05_0171.htm 9

Social and Emotional Behavioral Problems in Children with ADHD European survey of parents of children with ADHD (n=910) and without ADHD (N=995). *† p<.0001 , (Coghill et al., Child and adolescent psychiatry and mental health, 2:31,2008) 10

Emotional problems Low self-esteem 低自尊 Self-perception of incompetence 自覺無能力 焦慮 27-30% met criteria for an anxiety disorder (Biderman 1991) 28% of preschooler, 22% of school-age children (Wilens 2002) 憂鬱 25-30% of children with ADHD Because ADHD have many impairment in social relation and academic performance, they frequently hear that they are not doing well. As ADHD is lasting for long time, the children with ADHD may have low self esteem and they perceve they are not incompetent. so, many of them may have anxiety disorder and depression. according to one study, 27-30% of ADHD have Anxiety disorder. and 25-30% of children with ADHD have depression.

Peer relation More than 50% of children with ADHD have significant problems in peer relationship (Pelham 1982) Less knowledge about social skills, appropriate behavior with others (Grenell 1987) More likely to be engage in Bullying, Victimized in bullying episode (Unnever 2003) Children with ADHD are stigmatized by their behavior Troublemaking Excessive talking Breaking rules Impulsive aggression (Barkley 1991) as well as parent-child relation, children with ADHD have difficulty in peer relation.  more than 50% of children with ADHD have problems with their peer. Children with ADHD have poor social skills. They are more likely to be engage in bullying. on the other hands, They are also victimized in bullyng. because of their behavior, for example, trouble making, excessive talking, breaking rules and impulsive aggression, children with ADHD are stigmatized.

Parent-Child relation ADHD affects the interaction of children with their parents (especially with mother) Greater intrafamily conflicts (Danforth et al. 1991) Children with ADHD (Barkley 1985) More talkative, negative, and defiant Less compliant and cooperative Less able to play and work independently of their mother Mother of children with ADHD (Hoza et al. 2000) Low self-esteem Lower parenting efficacy Disturbance of interaction Stem from the effects of a child’s behavior rather than parent’s behavior on the child ( Fischer 1990) Ist domain of functional impairment is parent-child relationship During childhood, children with ADHD spend most of time with their parents, especially with their mother. But children with ADHD are more ……..So many conflict and problem can be ocurred with them. the family of ADHD children have more intrafamily conflict. parent of children with ADHD manifest greater parenting stress.  mother of ADHD have low self-esteem, and they feel they do not care their children enough. these disturbance of parent-child interaction is 엳 새 child's behavior rather than parent's behavior.

Academic & School performance Lower academic performance than their classmates By 10-30 points on standardized achievement test Including reading, spelling, math, and reading comprehension Disruptive classroom behavior Underperforming in school relative to ability Repetition of a grade (30% or more) Be placed in one or more special education programs (30-40%) Suspended from school (up to 46%) (Barkely et al. 1990) they also have some impairment in academic & school performance. as discussed earlier, they have poor academic skills. Including…………… so many of them repeat the grade, and have to be placed in special education. finally many of them are suspended from school. I'm sorry , But I don't know how many children with ADHD have to be suspended in Korea.

Impact of ADHD in adolescence Data from Barkley RA;26 (A) Impact at school; (B) impact on health, social, and psychiatric wellbeing.

Antisocial behaviour in adolescents with ADHD Data primarily represents outcomes in those with conduct disorder as teenagers Harpin, V A Arch Dis Child 2005;90:i2-i7

臨床評估 一、臨床晤談 二、醫學檢查 三、行為觀察 1. 家長晤談 2. 兒童晤談 3. 老師晤談 1. 身體檢查 2. 醫技檢驗 1. ADHD症狀觀察 2. 親子互動觀察

量表測驗評估 父母量表 教師量表 注意力測驗 衝動控制 神經心理功能 4-16歲兒童行為檢核表（家長用） ADHD量表（家長用） 活動量量表（家長用） 家庭情境量表 教師量表 4-16歲兒童行為檢核表（教師用） ADHD量表（學校版） 活動量量表（教師用） 學校情境量表 學業表現量表 注意力測驗 持續表現測驗（CPT） 刪除測驗（Cancellation tasks） 魏氏兒童智力測驗第三版--專心注意因素 衝動控制 相似圖形比對測驗（MFFT） 神經心理功能

認識 ADHD 青少年 過動情形可能較不明顯 注意力缺乏行為 學業成績不良 缺乏注意力 容易衝動 缺乏組織技巧 缺乏時間觀念 留意特定的學業困難： 學業成績不良：青少年似乎缺乏能記住細節的注意力，或似乎慢不經心。此外，可能無法專注在同一件工作直到完成作業。 注意力差：這可能因為做白日夢，接下來可能導致沒聽到訊息及沒聽到作業分配。 衝動：可能造成學生倉促完成工作、沒有閱讀指示以及沒有檢查及再檢查；所有這些都會導致不必要的錯誤以及失敗。 組織技巧差：不容易開始進行某項工作以及缺乏事先計畫。 時間觀念受損：他似乎很健忘，而且回憶的能力很差。有寫作表達的問題，且經常無法解決複雜問題。上學可能經常遲到，而且可能無法在規定日期交作業。 Ingram S. Mental Retardation and Development Disabilities Research Reviews. 1999;5:243. Weiss M, Jain U. ADHD Report. 2000;8:4-10.

認識 ADHD 其他合併症狀 超過 50% ADHD 青少年有其他合併症狀 約 50% ADHD 兒童具有學習障礙 50% 對立性反抗性行為 (Oppositional Defiant Disorder) 或行為規範障礙 (Conduct Disorder) 40% 焦慮 20% 憂鬱 30% 物質濫用行為 (Substance Use Disorder，包括吸毒, 抽煙, 酗酒, 藥物濫用) 約 50% ADHD 兒童具有學習障礙 當 ADHD 兒童進入青春期時，這個疾病可能把青少年帶往許多方向。家長和教師必須注意 ADHD 學生可能會發展出其他合併症狀。這表示學生可能有其他的行為問題。在所有 ADHD 學生中，超過一半的孩子會有一種合併症狀。這張幻燈片顯示其他合併症的盛行率。研究顯示最高有 50% 的ADHD青少年可能具有行為規範障礙(如逃家, 輟學, 偷竊, 說謊, 混幫派)或對立性反抗行為(頂嘴, 愛找藉口)；40% 可能會焦慮；超過 20% 可能有憂鬱症；而 30% 可能養成物質濫用行為(如抽煙, 酗酒, 吸毒等)。 約有 50% 的 ADHD 孩子有學習障礙，這需要接受心理教育學評估加以確定。請注意 ADHD 學生的學習障礙會發生在所有年齡，而且出現合併症的情形也非僅限於青少年。 Biederman J et al. Am J Psychiatry. 1991;148:564-577. Pomerleau OF et al. J Subst Abuse. 1995;7:373-378.

總結 ADHD 有許多面象 男孩通常比女孩早發現 注意力缺乏型較難發現，且較常發生於女孩 面臨ADHD青少年時代表著額外的挑戰 就觀察到的行為進行溝通 指引父母及ADHD青少年尋求專業醫療協助 [請讀出幻燈片中的項目]

治療 包含四大類： 尚需配合 (一)藥物治療 (二)行為管理或治療 (三)認知行為治療 (四)親職訓練 (五)課業輔導 (六)日常生活活動的安排

要過動的孩子不要動，不要打架，倒不如教他動的方法，動的得當，及與同儕相處之道，高壓強迫的方式並不能真正解決孩子的問題。希望能提昇孩子學習時的專注力，改善學習效果，只有讓孩子在學習成長中獲得快樂，才是促進學習的最大動力。

結論 全面性及長遠性的治療： 1. 不能只靠單一介入方法，也不能只有兒童本身參與就好 ，周圍的人必須共同參與介入計畫。 1. 不能只靠單一介入方法，也不能只有兒童本身參與就好 ，周圍的人必須共同參與介入計畫。 2. 症狀、衍生問題、人際互動等會隨年齡增長而產生改變，對兒童的介入方式需考慮發展上的變化，並依此做相對的調整。