注意力不足過動症
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注意力不足過動症(Attention-deficit hyperactivity disorder，簡稱ADHD)是一種在兒童期很常見的精神失調。根據世界衛生組織的《世界通用疾病分類手冊》第十版(ICD-10，WHO，1992)稱此症為“過度活躍症”(Hyperkinetic Disorder)，分類編號為F90，一般又俗稱為「過動兒」。由於對這種病症的認識增加，最近大家才發現這種病症同樣在成年人身上出現。
現時沒有任何確切證據證實任何導致這種病症的原因，但過去曾經推測味精可能是一種誘因。但隨著醫學界發現成人亦患有這種病以後，這種說法站不住腳。根據美國疾病控制及防禦中心(CDC)的研究，ADHD其實只是多種精神失調的合稱。因此，要正確疹斷這一病症，不能依靠單一測試去確定，而必須同時採用多種測試配合去確認。
對ADHD比較確切的定義，記載於美國精神醫學會(APA)出版的《精神疾病診斷與統計手冊》第四版文本修改版(DSM-IV-TR，APA，2000年)。ADHD的主要病徵是：
- 注意力散渙 (inattentive) 或 集中困難 (Attention-deficit)
- 活動量過多 (hyperactive 或 hyperkinetic)
- 自制力弱 (impulsive)
而基於以上三種病徵出現的優勢，再把ADHD細分為以下三個分類：
- 注意力散渙主導型 (mainly inattentive)
- 活動量過多或自制力弱主導型(mainly hyperactive-impulsive)
- 混合型 (combination)
根據最近的研究發現，ADHD是由一種發生於腦前額葉的遺傳性的多巴胺新陳代謝失常引致。最新的研究認為正腎上腺素 (norepinephrine)的新陳代謝亦會對病情有所影響。(參看Krause et al，2000)但由於這些最新研究都有藥廠在背後資助，其中立性尚有待確認。
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[编辑] 名稱
注意力不足症(Attention Deficit Disorder，簡稱ADD)這個名詞首先於1980年出版的DSM第三版出現。在1987年出版的修訂本中，才改用現在的名稱。這個病症在台灣被稱為注意力缺失過動疾患，在香港被稱為專注力失調過度活躍症，而在日本則被稱為注意欠陷多動性障害。在韓國則被稱為注意力缺乏過剩行動障礙(주의력결핍 과잉행동장애)。
除了ADHD或ADD以外，過去也曾採用過度活躍症或多動症候群(Hyperkinetic Syndrome，簡稱HKS)；微細腦損傷、微細腦機能障礙(Minimal Cerebral Dysfunction，簡稱MCD)等各種名稱。此外，外國出版物有時為了迴避“disorder”這一個比較負面的詞語，會改稱為Attention-Deficit Syndrome(注意力不足候群，簡稱ADS)。
[编辑] 症狀
有ADHD的小朋友，其表現通常有注意力不集中、無法抑制自己的衝動以及坐立不安的情況。 在大人，主要問題則常在於ADHD患者無法計畫好他們的生活與每日簡單的工作，因此注意力不集中與坐立不安的情況常是次要的問題。 診斷ADHD的標準係依據DSM-IV-TR的標準，可以連結至美國疾病管制局Centers for Disease Control and Prevention (CDC)[1]查詢。美國疾病管制局強調診斷ADHD必須由受過專業訓練的醫療提供者才可，否則容易被誤診與處方，這是相當危險的。
[编辑] 在教室內的行為觀察
一個有ADHD的學生，在課室內可能有以下的行為。然而這些行為不能作為其患病的確診，因為其他病症的患者亦會出現類似的病徵，但可以作為轉介與學校社工的指標。這些行為的部份列表如下：
- 有「手腳搖動」的行為，即俗語所謂的「坐立不定」。
[编辑] 20世紀歷史
1902年，英國兒科醫生George Still首次描述一項與ADHD近似的病徵。condition analogous to ADHD. He regarded it as innate and not caused by the environment.
The 1918–1919 influenza pandemic left many survivors with encephalitis, affecting their neurological functions. Some of these exhibited immediate behavioural problems which correspond to ADD. This caused many to believe that the condition was the result of injury rather than genetics.
1937年，一家醫院首次採用安非他命來治療有行為問題的兒童。兒童接受治療後，行為有改進。不過，這種治療法在1950年代以前都不太普遍。
1957年，利配酮開始被廣泛應用於治療。
1950年代至1960年代，研究人員對這種病症的名稱開始由“微細腦創傷”改為“微細腦功能失常”。改變名稱的原因，是因為不少病童都沒有發覺有受過任何創傷。
1960年代，“過度活躍兒童候群”這名稱首次出現。當時專家認為這些症狀並非由損傷引起。到了1960年代後期至1970年代，“過度活躍”這名詞已在歐美社會變得很普遍，但醫學上普遍採用“MBD”來稱呼這些症狀。
In the early 1970s an erroneous newspaper article, which is still often cited, inflated the prescribing rate of medication by a factor of 10, influencing some to avoid treatment with stimulants.
In 1973 Dr Ben F. Feingold, once a Professor of Allergy in San Fransisco, claimed that hyperactivity was increasing in proportion to the level of food additives, and proposed a specific diet believing that it would help 50% of hyperactive children.
The popularity of the claims caused an American Congressional Commission to investigate additives and encourage research. Most carefully controlled studies showed that only 5% of ADD children were impacted by food (but this was obviously an important finding for that 5%), but some have shown a figure of 60%. One study tested the 50% who claimed to be helped by diet, finding that 10% showed behavioural changes from food triggers. The Feingold diet excluded cola drinks, chocolate, preservatives and flavour additives, as well as salicylates that occur naturally in fruit such as tomatoes, strawberries, pineapples and oranges. However pineapple juice was suggested as a "safe" drink. Professional dieticians exclude and re-introduce food groups on a more controlled basis to identify triggers.
The Canadian Virginia Douglas in the early 1970s made various publications to promote the idea that attention deficit was of more significance that the hyperactivity, influencing the American Psychiatric Association. The name attention deficit disorder (ADD) was first introduced in DSM-III, the 1980 edition.
1980年代，這種病症開始在亞洲得到注意，主要是因為當時亞洲的新興經濟勢力地區開始發現當地兒童的飲食轉變可能與過度活躍兒童的增加有關。當時南華早報曾就此事件發表專題報導，而這報導後來成為了香港某一年高考英語運用科的題目取材。
另一方面，在西方有研究員發現維生素B6能夠使有學習困難的兒童在課堂上更能專注，而這種處方對於注意力不足的學童有同樣的療效。其後，再有研究指鋅能對注意力不足及患自閉症的學童有所幫助。之後，多樣維生素成為了部份醫生對這些病童的處方。不過，這些研究在事後發現可信程度不太高。
In the mid-1980s, Helen Irlen from California took out a patent on certain tints for lenses to help those with reading problems. Despite wide media coverage and a number of studies, it appears that only a small percentage of subjects saw improvement.
In the late 1980s, the Church of Scientology set up the Citizen's Commission on Human Rights (CCHR), which lobbied using the media against psychiatric medication in general, and Ritalin in particular. They were very effective at the time in scaring people away from treatment with stimulants, as well as increasing the social stigma.
In 1994, DSM-IV described three groupings within ADHD, which can be simplified as: mainly inattentive; mainly hyperactive-impulsive; and both in combination.
[编辑] 個案數字
[编辑] 美國的數字
根據2000年版本的DSM-IV-TR，在美國大概有3%-7%的兒童有ADHD。而根據美國疾病控制中心於2004年出版的美國健康訪問調查年報，美國大約有400萬名18歲以下的兒童被診斷出有ADHD。不過，有關評估的比率差異極大，有些校區甚至有60%的兒童被診斷為ADHD患者。現時美國全國有超過100萬成年人及小童因為這個病症而需要服用處方的藥物。
根據2002年的統計數字，被診斷出有ADHD的男童在比例上比女童高出兩倍(男童比例：10%；女童比例：4%)。對於這個性別上差異的成因，我們仍然未知確切原因。不過，有專家指有可能由於女童的病症普遍比男童輕微，在診斷時亦同時較男童難於察覺，所以較少被家長及老師發現而作出轉介。
[编辑] 香港的數字
在香港，現時由於過去資源分配的問題，教統局一直都未有抽撥任何資源去探究這個問題。直到2004年11月到12月，教統局才首次在全香港進行系統性的普查，研究在實施融合教育之後，每一家學校的弱能學生所佔的比例。不過就部份現職老師非正式從各自學校的觀察，亦發現一項與美國的研究類似的結果，就是：男童的比例比女童為高，而女童通常都較遲才被發現有這個問題。老師們推斷這可能與香港的女童普遍較男童文靜有關，但仍需要研究去確認。
[编辑] 數字背後的意義
今天ADHD是多动症的一个问题是工业化世界各地, 虽然没有其他国家的孩子得了这种"无序"经常在美国.
The variation in the rates of diagnosis and in estimates of the rate of prevalence raises numerous issues. In fact, almost everything about ADHD has been the subject of intense debate, as discussed later in this article. This debate led the NIH to develop a Consensus Statement in 1998, a link to which is provided in the External Links section below.
ADHD often continues into adolescence and adulthood, and can cause a lifetime of frustrated dreams and emotional pain. However, children diagnosed with ADHD often go on to live normal lives, and wonder why their parents and schools felt the need to medicate them. Many complain of having needlessly suffered from the psychological trauma of the diagnosis and adverse effects of the drugs. Others have written of how diagnosis and treatment improved their lives.
[编辑] Evidence for ADHD as an organic phenomenon
利用磁共振顯像技術(MRI)對腦部掃描的研究顯示患有ADHD和正常孩子的圖象有分別。不少科學家認為這足以證明ADHD是和腦部創傷有關。但另一方面，根據腦部的正電子造像顯示，這種分別很可能只說明了ADHD患者的問題：因為他們並不能專注於一件事情，所以腦部影像只說明了作為腦內燃料的葡萄糖的分佈，在兩組兒童之間的分別。在成人患者的腦掃描中，控制專注力的部份由於葡萄糖水平較低，所以顯得不太活躍(Zametkin et al.)。 不過，沒有證據顯示低葡萄糖水平與低注意力有關連。
Maybe even more interesting are the results of some studies using SPECT (Single Photon Emission Computed Tomography). One study (Lou et al. in Arch. Neurol. 46(1989) 48-52) found that people with ADHD have a reduced blood circulation in the striatum. But even more important might be the discovery that people with ADHD seem to have a significantly higher concentration of dopamine transporters in the striatum (Dougherty et al. in Lancet 354 (1999) 2132-2133; Dresel et al. in Eur.J.Nucl.Med. 25 (1998) 31-39).
It has been known for some decades that head injuries can produce ADHD-type behaviour.
[编辑] ADHD會不會遺傳？
根據NIMH的答問集，茲引文如下：
- “研究顯示ADHD會在家族中出現，所以有一定程度的遺傳影響。ADHD的病童通常都至少有一位近親亦有ADHD。患有ADHD的男童長大成為父親後，不少於三分一人的子女亦是ADHD患者。一個更有說服力的遺傳聯繫，就是同卵雙生兒如果當中一位被診斷為ADHD患者，另一位同時亦是患者的機會非常高。”
[编辑] 以正面態度面對
Though ADHD is classified as a serious disorder, many people have a different perspective. Some see it as a gift. In his book ADD - Attention Deficit Disorder (1997), Thom Hartmann developed the idea that people having ADHD symptoms may have simply inherited a collection of genes that were selected for when hunting was particularly important. This idea is the basis of another of his works, The Edison Gene: ADHD and the Gift of the Hunter Child (2003).
People who believe that ADHD is a gift find hints of ADHD in the lives of many famous people in history. Though such post mortem diagnosis is questionable, it is intriguing to ponder the evidence that people such as Thomas Edison might have been diagnosed as having ADHD if the current DSM criteria had been developed sufficiently long ago.
除了愛迪生以外，以下各個歷史人物也被後世科學家認為帶有ADHD的徵狀：
此外，亦有人認為當今世上的下列人物也可能有ADHD：
To see ADHD as a gift may seem somewhat problematic to anxious parents but it is at least a perspective that should be kept in mind.
[编辑] Psychological testing for ADHD
Psychological testing for ADHD generally consists of obtaining multiple types of assessments. These usually include a clinical interview reviewing the DSM-IV criteria for ADHD. The interview also needs to rule out as much as possible other types of syndromes which can cause attention problems, such as depression, anxiety, and psychosis. Rating scales can be administered which provide measurement of the person's own view of their symptoms, as well as the views of parents, teachers, and significant others. Finally, computerized tests of attention can be helpful in providing a further independent assessment. These different assessments may not be in total agreement but provide a well-rounded view of the person's difficulties. A physician need not order psychological testing in order to make the diagnosis of ADHD, but many doctors use this kind of assessment to avoid over-diagnosis and treatment.
Neurometrics, PET scans, or SPECT scans have been used for a more objective diagnosis. These are not usually suitable for very young children.
Attention deficit disorder also exists in adults, and an assessment for this is also needed.
[编辑] Skepticism towards ADHD as a diagnosis
It should be noted that many creative individuals exhibit the characteristics of ADD or ADHD by virtue merely of the natural diversity of their paths of thinking. As in the case of many, if not all, others who exhibit the characteristics, there is no cause to suppose that it is their constitution, and not that of society generally, that is a condition to be rectified.
Critics have complained that the ADHD diagnostic criteria are sufficiently general or vague to allow most children with persistent unwanted behaviors to be classified as having ADHD of one type or another. This can be seen as diluting the perceived importance of the disorder. It should be noted that diagnostic questionnaires are often subject to copyright restrictions, preventing a wider awareness of their specificness.
Many people have wondered why the number of children diagnosed with ADHD in the U.S. and UK has grown so dramatically over a short period of time. It has often been suggested that the causes of the ADHD epidemic lie in cultural patterns that variously encourage or sanction the use of drugs as a simple cure for complex problems. Some critics assert that many kids are diagnosed with ADHD and put on drugs as a substitute for parental attention, whereas many parents of ADHD children assert that the associated demand for attention goes beyond what can be humanly provided, causing massive disruption to other individuals and relationships, as well as to environments with structured relationships such as classrooms. This criticism also includes the use of prescription drugs as a substitute for parental duties such as communication and supervision.
Some schools have required "problem" pupils to undergo ADHD diagnosis (and treatment if diagnosed), which has caused protests. Some critics have suggested that the ADHD label should be abolished.
Douglass Rushkoff, among other critics of ADHD diagnosis, suggest that the disorder may be a result of cultural conditions to which children and adults alike are subjected. Primary among these is the omnipresence and exploitive qualities of advertising. In the time that ADHD has arisen as the epidemic it is often portrayed as, advertisement has become virtually unavoidable, and advertisements utilize much more sophisticated methods of deception. Some suggest that people (children, especially) are aware of this attempt at pervasive trickery, whether consciously or subconsciously, and react by avoiding extended attention in order to avoid being deceived. Naturally, this self-defense reaction, when carried over to school and home, presents obvious problems. From this point of view, prescribing drugs is effectively only to alleviate symptoms, but entirely avoids the cause.
Thom Hartmann, among others take an approach from biological evolution to argue, that ADHD is not a disorder, but an expression of biodiversity. From an evoluitionary point it is quite acceptable that humans - like animals - differ in their biology and pass on their traits from generation to generation. It has not yet been proven wrong that ADHD in deed could be product from human evolution, and therefore not a disability, disorder, condition or mental illness.
Another source of sceptism towards making the diagnosis of "ADHD or not ADHD" may arise from the rising diagnosis of subclinical forms of ADHD. So called "Shadow-syndromes" or "sub-syndromes" stand for weaker forms of ADHD and are described in various degress by John J. Ratey and Catherine Johnson on their book "Shadow Syndromes: The Mild Forms of Major Mental Disorders That Sabotage Us".
[编辑] 治疗
目前可用于治疗ADHD患者的数种方案包括各种医药治疗、行为干预、以及教育疗法。
[编辑] 医药治疗
针对ADHD的一线药物为兴奋剂，其中包括诺华公司的立达宁(Ritalin，学名为哌甲酯(methylphenidate))、沙尔公司的Adderall(安非他明产品，主要成分为右旋苯丙胺(dextroamphetamine)和laevoamphetamine salts)、Ovation制药公司的Desoxyn(学名为甲基安非它明(methamphetamine)等。由于几乎所有针对ADHD的药品都被美国缉毒署划分为二级管制品(Schedule II，即指有高度滥用可能性的药品)and are considered powerful stimulants with a potential for diversion and abuse, there is controversy surrounding prescribing these drugs for children and adolescents.
However, research studying ADHD sufferers who either receive treatment with stimulants or go untreated has indicated that those treated with stimulants are in fact much less likely to abuse any substance than ADHD sufferers who are not treated with stimulants.
Second-line medications include less-powerful stimulants such as benzphetamine and Provigil/modafinil, although research as to the efficacy of these drugs is not complete.
Data from 1995 show that physicians treating children and adolescents wrote six million prescriptions for stimulants. Of all the drugs used to treat psychiatric disorders in children, stimulant medications are the most well-studied. However, to date there are no good long-term studies dealing with stimulants in children. A 1998 Consensus Development Conference on ADHD sponsored by the National Institutes of Health and a recent, comprehensive, scientific report confirmed many earlier studies showing that short-term use of stimulants is safe and effective for children with ADHD. This says nothing for the growing number of children who are on stimulants for years at a time. Some non-stimulant medications are now becoming available to treat ADHD such as Strattera (atomoxetine HCl), a selective norepinephrine reuptake inhibitor.
In December 1999, NIMH released the results of a study of nearly 600 elementary school children, ages seven-to-nine, which evaluated the safety and relative effectiveness of the leading treatments for ADHD for a period up to fourteen months. The results indicate that the use of stimulants alone is more effective than behavioral therapies in controlling the core symptoms of ADHD - inattention, hyperactivity/impulsiveness, and aggression. In other areas of functioning, such as anxiety symptoms, academic performance, and social skills, the combination of stimulant use with intensive behavioral therapies was consistently more effective. (Of note, families and teachers reported somewhat higher levels of satisfaction for those treatments that included the behavioral therapy components.) NIMH researchers will continue to track these children into adolescence to evaluate the long-term outcomes of these treatments, and ongoing reports will be published. This study has been severely criticized, as it was not double-blind and the sponsors failed to provide a control group.
There has been a lot of interesting work done with neurofeedback and ADHD. Children are taught, using video game-like technology, how to control their brain waves. This has a very high success rate, but is not widely used, or covered by insurance. Many professionals consider the treatment promising, but state that there is not yet sufficient evidence that it works after the immediate treatment is complete. Dietary and television restrictions are also sometimes useful environmental solutions. Sugar, wheat, and other foodstuffs have been shown to cause adverse behavioral reactions.
2004年4月，美國食品及藥物管理局曾發表報告，指有51位美國人因為服食ADHD藥物而死亡。，而在香港，亦有零星個案指病童在服食過醫院處方的藥物後出現心臟病的症狀，而這些病童在服藥前都沒有被診斷出曾有心臟病。就此，美國的心臟病學家尼森及食品及藥物管理局的一個專家小組都希望局方能夠在藥物上加上新的警告，並採取措施防止醫生濫開這些藥物，以避免更多病人受害。
[编辑] 行为干预
[编辑] 教育疗法
[编辑] Other ADHD-related controversies
There are other controversies intersecting with ADHD, to do with:
- prescribing psycho-active medication to children in general,
- prescribing medication for mental illness at all,
- psychiatry itself (see Anti-psychiatry), and
- the involvement of the Church of Scientology in opposing specific treatments.
The controversies attract popular attention including the mass media. Media critics in the scientific community say that, despite often employing science reporters, such reporters have inherent inabilities to accurately report on scientific papers without sensationalising them, using exaggeration, undue emphasis of aspects, taking aspects out of context, and publishing point-of-view features within news contexts. They also say the mass media fails to identify procedural lapses in studies allowing dubious conclusions to be publicized. Such lapses include: lack of peer review, small sample sizes, lack of published error ranges, filtering of results, lack of control groups and lack of use of double-blind techniques or placebos. Examples of cited of such media misrepresentation include the University of Washington study (see below), which was widely reported as proving that television causes ADHD, despite disclaimers within the published study apparently seeking to avoid this very headline.
- The Norwegian scientist Dr. Karl Ludwig Reichelt claims that peptides from casein (milk-protein) and gluten (grain-protein) worsen the symptoms in many ADHD-patients. Extensive testing of ADHD-patients is taking place in Norway, and diet has astonishing effects for many of them. Although good result are achieved in Norway, the peptide-theory is discarded by the scientific community.
[编辑] 參考書目
[编辑] 英文版原文參考
- Understanding ADD by Dr Christopher Green & Dr Kit Chee, ISBN 0-86824-587-9, Doubleday 1994
- The ADHD-Autism Connection: A Step toward more accurate diagnosis and effective treatment, by Diane M. Kennedy, ISBN 1578564980 (The aim of this book is to explore the similarities that attention deficit hyperactivity disorder (ADHD) shares with a spectrum of disorders currently known as pervasive developmental disorders.)
- Krause, Dresel, Krause in Psycho 26/2000 p.199ff
[编辑] 中文版參考
- ^ 世界卫生组织(2003年)：《成人自测计分1.1 版(ASRS-V1.1) 检测表》，http://www.hcp.med.harvard.edu/ncs/adhd/6Q-Chinese-Mandarin.pdf ，瀏覽日期：2004年9月30日。
- ^ 翁士恆，(2003年)，《停不了的小馬達：ADHD─注意力缺失/過動疾患》，台灣中國醫藥大學附設醫院兒科部親子諮詢中心，http://www.cmuh.org.tw/HTML/dept/1500-1/03/htm/adhd.htm，瀏覽日期：2004年10月11日
- ^ 日本文部科學省，(2003年)，《今後の特別支援教育の在り方について（最終報告）》：（参考３） 定義と判断基準（試案）等。http://www.ne.jp/asahi/hp/keyaki/NEW/sp_sp_ed/208.html，瀏覽日期：2004年10月11日
- ^ 服用ADHD藥 心臟病風險增，《快線周報》2006年2月11日號，第10版，香港：星島報業集團。
[编辑] 外部連結
- DSM-IV-TR Criteria for ADHD
- ADHD Discussion Forum
- NIH Consensus Statement, 1998
- ADHD questions and answers
- A view that ADHD is a desired quality
- CDC's ADHD page
- http://www.nimh.nih.gov/publicat/adhd.cfm 美國國立精神健康機構有關ADHD的網頁。本網頁的內容為public domain resource
- http://www.nimh.nih.gov/publicat/adhdqa.cfm 美國國立精神健康機構有關ADHD的FAQ
- ADD and ADHD: An Overview for School Counselors. ERIC Digest.
- Adults with Attention Deficit Hyperactivity Disorder (ADHD). ERIC Digest.
- ADHD and Children Who Are Gifted. ERIC Digest.
- CHADD - A large USA non-profit organization providing education, advocacy and support for individuals with AD/HD
- University of Washington study linking TV at ages 1 & 3 to less attentiveness derived from hyperactivity (PDF)
- ADD/ADHD From a Parent's Perspective
- Mental Health Matters: ADHD Information Page
- A paper on using Bayesian probablity for better ADHD diagnosis
