智能障礙與自閉癥課件

智能障礙與自閉癥智能障礙與自閉癥智能障礙與自閉癥智能障礙與自閉癥智能障礙自閉癥智能障礙與自閉癥智能障礙(Mentalretardation)智能障礙與自閉癥智能障礙智能障礙的診斷智能障礙的流行病學(xué)智能障礙的病因智能障礙的臨床癥狀及行為問(wèn)題智能障礙的治療與預(yù)後智能障礙與牙科智能障礙與自閉癥智能障礙的診斷智能障礙:是癥狀也是診斷智能障礙與自閉癥智能障礙的診斷啟蒙時(shí)代19世紀(jì)20世紀(jì):Stanford-BinettestDr.LangdonDown

從特教到預(yù)防智能障礙與自閉癥智能障礙的診斷DSM-IV(DiagnosticandStatisticalManualofMentalDisorders,4thedition):精神疾病診斷統(tǒng)計(jì)手冊(cè)第四版ICD-10(TenthRevisionoftheInternationalClassificationofDiseasesandRelatedHealthProblems):國(guó)際疾病分類診斷系統(tǒng)智能障礙與自閉癥智能障礙的診斷:DSM-IVcriteria1.

Intellectualfunctioningsignificantlybelowaverage.

IQsofabout70orlowerinpersonwhocantakeanIQtest.

ClinicaljudgmentmustbeuseonthosewhocannottakeanIQtest.2.

Impairmentsordeficitsforthatagegroupinfunctioninginatlasttwoofthefollowingareas:Communication.Health.Leisuretime.Safety.School.Self-care.Social.Takingcareofahome.Work.3.

Theonsetofimpairmentmustbebeforetheageofeighteen.智能障礙與自閉癥智能障礙的診斷輕度智能障礙:IQ50-55到70中度智能障礙:IQ35-40到50-55重度智能障礙:IQ20-25to35-40極重度智能障礙:IQ<20-25智能障礙與自閉癥智能障礙的流行病學(xué)盛行率:1.3-2.3%男性較多85%為輕度智能障礙;10%為中度;4%為重度;及重度約佔(zhàn)1%社經(jīng)地位低及某些國(guó)外少數(shù)民族有較高盛行率智能障礙與自閉癥智能障礙的病因只有一半的智能障礙者找的到確切的病因大部份輕度智能障礙並無(wú)明確的原因:社會(huì)文化的影響(貧窮,低社經(jīng)階層,父母低IQ….)輕度智能障礙還是”正常分布的下緣”

?智能障礙與自閉癥智能障礙的病因有一半的智能障礙找得到原因>1000種已知的基因與智能障礙有關(guān)所有智能障礙者中的1/3有目前已知的基因異常,如:Downsyndrome,FragileXsyndrome,Prader-Willisyndrome,Williamssyndrome...etc智能障礙與自閉癥智能障礙的病因輕度智能障礙者中,10-45%有已知的基因異常,他們常屬於上述癥候群中的”高功能者”智能障礙與自閉癥智能障礙的病因Downsyndrome,FragileXsyndrome,Prader-Willisyndrome,Williamsyndrome不同的疾病,不同的認(rèn)知功能,不同的外顯行為,不同的合併癥因著每個(gè)病人的認(rèn)知功能”強(qiáng)項(xiàng)”所在,找出適合的溝通方式與行為處理原則智能障礙與自閉癥智能障礙的臨床癥狀及行為問(wèn)題臨床癥狀與IQ有很大的相關(guān)性IQ越低,常會(huì)越早被診斷輕度智能障礙是因?yàn)閷W(xué)習(xí)跟不上,到了小學(xué)後才被診斷,絕大多數(shù)的輕度智障者擁有正常的外觀,正常的生理機(jī)能與正常的自我照顧能力輕度智能障礙:可教育的(educable)智能障礙與自閉癥智能障礙的臨床癥狀及行為問(wèn)題中度以上的智能障礙(IQ<50):可訓(xùn)練的(trainable)中度以上的智能障礙:更多的功能缺損

Communication.Health.Leisuretime.Safety.School.Self-care.Social.Takingcareofahome.Work.智能障礙與自閉癥智能障礙的臨床癥狀及行為問(wèn)題行為問(wèn)題:求同存異特殊行為與共同行為智能障礙與自閉癥智能障礙的臨床癥狀及行為問(wèn)題特殊行為問(wèn)題:不同疾病常有屬於該疾病獨(dú)特的行為出現(xiàn)Angelman’ssyndrome:傻笑Prader-Willi:強(qiáng)迫性暴食FragileX:社交障礙,社交焦慮Downsyndrome:固著,異常固執(zhí)與堅(jiān)持智能障礙與自閉癥智能障礙的臨床癥狀及行為問(wèn)題共同行為:不同疾病間常有共同的問(wèn)題行為出現(xiàn)FragileX,William’ssyndrome:注意力不足智能障礙與自閉癥智能障礙的臨床癥狀及行為問(wèn)題其他常見(jiàn)行為:自傷,暴怒,對(duì)立反抗智能障礙與自閉癥智能障礙的臨床癥狀及行為問(wèn)題較易合併其他精神或神經(jīng)疾患:精神分裂癥,情緒疾患,注意力不足過(guò)動(dòng)癥候群,癲癇,早發(fā)性失智癥…等智能障礙與自閉癥智能障礙的治療社區(qū)化的治療智能障礙的治療考慮:智能不足的原因,IQ,年齡,生理與精神的合併癥許多的治療指南對(duì)罕見(jiàn)疾病不利智能障礙與自閉癥智能障礙的預(yù)後75%輕度智能障礙者成年後不需要機(jī)構(gòu)的協(xié)助,25%功能良好,有部分因功能良好,在成年後不再”符合”診斷中度智能不足者普遍需仰賴機(jī)構(gòu)協(xié)助,即使成年後,完全或者半依賴機(jī)構(gòu)的情形仍然存在重度及極重度智能障礙:需監(jiān)督與協(xié)助智能障礙與自閉癥智能障礙的預(yù)後早期診斷,早期介入,特殊教育,社會(huì)立法,法律協(xié)助有助於智能障礙者的預(yù)後智能障礙與自閉癥智能障礙與牙科獨(dú)特之口腔疾病及特徵二次性障礙所造成智能障礙與自閉癥智能障礙與牙科不同疾病有時(shí)會(huì)有不同口腔病徵:Williamssyndrome及Downsyndrome相同特徵:口腔健康狀況不佳,齲齒智能障礙與自閉癥智能障礙與牙科口腔清潔維持困難(AlfonsoEscribanoHernández

etal,MedOralPatolOralCirBucal.2007Nov1;12(7):E492-5.)資源尋找的困難(MaureenL.Pezzementietal,JAmDentAssoc2005;136;903-912)難以配合完整療程(MaureenL.Pezzementietal,JAmDentAssoc2005;136;903-912)智障者對(duì)於口腔衛(wèi)生的態(tài)度(HallburgU,ActaOdontolScand.2007Oct;65(5):265-70.)牙醫(yī)師/牙醫(yī)學(xué)生對(duì)於智能障礙患者的態(tài)度(AdamJ.Wolff,JAmDentAssoc2004;135;353-357)智能障礙與自閉癥智能障礙者的去敏感化衛(wèi)教Tell-Show-Do口語(yǔ)化或是視覺(jué)化(CaroleConyers,JournalofAppliedBehaviorAnalysis2004,37,233–238)智能障礙與自閉癥智能障礙者診療體位及行為處理無(wú)特殊體位上之要求說(shuō)話語(yǔ)氣要和緩、平順臉部表情要微笑、親切動(dòng)作要穩(wěn)重、勿急躁，

但要乾淨(jìng)俐落智能障礙與自閉癥智能障礙者牙科臨床輕度或中度者以一般的行為處理重度以上者大多依賴藥物吸入鎮(zhèn)靜

靜脈鎮(zhèn)靜

全身麻醉休息時(shí)間智能障礙與自閉癥自閉癥(Autism)智能障礙與自閉癥自閉癥自閉癥的診斷自閉癥的流行病學(xué)自閉癥的病因自閉癥的臨床癥狀及行為問(wèn)題自閉癥的治療與預(yù)後自閉癥與牙科智能障礙與自閉癥自閉癥的診斷Kraeplin:早發(fā)性癡呆(精神分裂癥)Bruler:4A(association,affect,ambivalence,autism)兒童精神分裂癥/兒童期精神病Kanner(1943):嬰兒期自閉(autism)智能障礙與自閉癥自閉癥的診斷Kanner最初的描述:先天性的無(wú)法和人產(chǎn)生有意義的連結(jié),仿說(shuō),異常固執(zhí),無(wú)法忍受變化,怪異的重複行為Kanner的錯(cuò)誤:正常的智力,父母的教育程度,使用autism在當(dāng)時(shí)暗示了其與精神分裂癥的關(guān)連智能障礙與自閉癥自閉癥的診斷DSM-III正式納入自閉癥的診斷DSM-III的缺失:診斷過(guò)於寬鬆,廣泛DSM-IV修訂智能障礙與自閉癥自閉癥的診斷:DSM-IVcriteriaA.Qualitativeimpairmentinsocialinteraction,asmanifestedbyatleasttwoofthefollowing:1.markedimpairmentsintheuseofmultiplenonverbalbehaviorssuchaseye-to-eyegaze,facialexpression,bodypostures,andgesturestoregulatesocialinteraction2.failuretodeveloppeerrelationshipsappropriatetodevelopmentallevel3.alackofspontaneousseekingtoshareenjoyment,interests,orachievementswithotherpeople(e.g.byalackofshowing,bringing,orpointingoutobjectsofinteresttootherpeople)4.lackofsocialoremotionalreciprocity智能障礙與自閉癥自閉癥的診斷:DSM-IVcriteriaB.qualitativeimpairmentsincommunicationasmanifestedbyatleastoneofthefollowing:

1.delayin,ortotallackof,thedevelopmentofspokenlanguage(notaccompaniedbyanattempttocompensatethroughalternativemodesofcommunicationsuchasgestureormime)2.inindividualswithadequatespeech,markedimpairmentintheabilitytoinitiateorsustainaconversationwithothers3.stereotypedandrepetitiveuseoflanguageoridiosyncraticlanguage4.lackofvaried,spontaneousmake-believeplayorsocialimitativeplayappropriatetodevelopmentallevel

智能障礙與自閉癥自閉癥的診斷:DSM-IVcriteriaC.Restrictedrepetitiveandstereotypedpatternsofbehavior,interests,andactivities,asmanifestedbyatleastoneofthefollowing:1.encompassingpreoccupationwithoneormorestereotypedandrestrictedpatternsofinterestthatisabnormaleitherinintensityorfocus2.apparentlyinflexibleadherencetospecific,nonfunctionalroutinesorrituals3.stereotypedandrepetitivemotormannerisms(e.g.,handorfingerflappingortwisting,orcomplexwhole-bodymovements)4.persistentpreoccupationwithpartsofobjects智能障礙與自閉癥自閉癥的診斷:DSM-IVcriteriaD.Delaysorabnormalfunctioninginatleastoneofthefollowingareas,withonsetpriortoage3years:(A)socialinteraction

(B)languageasusedinsocialcommunication

(C)symbolicorimaginativeplay

E.ThedisturbanceisnotbetteraccountedforbyRett'sDisorderorChildhoodDisintegrativeDisorder

智能障礙與自閉癥自閉癥的流行病學(xué)盛行率:2.5-72.6/10,000(1987-)11.3/10,000盛行率越來(lái)越高智能障礙與自閉癥自閉癥的流行病學(xué)男性為女性4.3倍女性比男性易有智能障礙問(wèn)題智能障礙與自閉癥自閉癥的病因1950-1960s:照顧者/雙親的問(wèn)題(標(biāo)籤化)生物醫(yī)學(xué)(腦部構(gòu)造,神經(jīng)傳導(dǎo)物質(zhì),神經(jīng)生理功能,鏡像神經(jīng)元…etc)遺傳學(xué)/分子生物學(xué)(極高的遺傳率:>90%)認(rèn)知/神經(jīng)心理學(xué):心智理論(theoryofmind),共享式注意力(jointattention)智能障礙與自閉癥自閉癥的臨床癥狀及行為問(wèn)題1-2歲之間發(fā)病社交障礙溝通障礙:溝通能力與預(yù)後相關(guān)認(rèn)知發(fā)展:超過(guò)1/2以上智能不足,與預(yù)後有關(guān)行為問(wèn)題智能障礙與自閉癥自閉癥的臨床癥狀及行為問(wèn)題易合併注意力不足或過(guò)動(dòng)癥狀年紀(jì)漸增:情緒障礙,焦慮與憂鬱智能障礙與自閉癥自閉癥的臨床癥狀及行為問(wèn)題生理異常:腦波神經(jīng)學(xué)共病:FragileX,tuberoussclerosis,PKU(phenylketonuria),癲癇智能障礙與自閉癥自閉癥的治療早期發(fā)現(xiàn),早期介入特殊教育應(yīng)用行為分析(appliedbehavioranalysis)TEACCH模式(TreatmentandEducationofAutisticandrelatedCommunicationhandicappedChildren)DIR(development,individual,relationship)/地板時(shí)間(floor-time)智能障礙與自閉癥自閉癥的治療

藥物治療第二代抗精神藥物/情緒穩(wěn)定劑:行為問(wèn)題,暴力,衝動(dòng)中樞神經(jīng)活化劑:注意力不足過(guò)動(dòng)癥狀智能障礙與自閉癥自閉癥的預(yù)後學(xué)齡前:癥狀典型就學(xué)後:可稍增加社會(huì)行為早期介入:預(yù)後佳1/3成人後可獨(dú)立生活,其於依賴或半依賴機(jī)構(gòu)的協(xié)助智能障礙與自