房夏玲,高文娟,陳 寧,劉小紅,史瑞明
(西安交通大學(xué)第一附屬醫(yī)院兒科,陜西 西安 710061)
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抽動(dòng)障礙患兒及父母心理干預(yù)的臨床研究
房夏玲,高文娟,陳寧,劉小紅,史瑞明
(西安交通大學(xué)第一附屬醫(yī)院兒科,陜西 西安 710061)
目的探討抽動(dòng)障礙患兒及父母的心理干預(yù)在輔助藥物治療兒童抽動(dòng)障礙中的重要作用。方法收集西安交通大學(xué)第一附屬醫(yī)院兒科門診就診的50例抽動(dòng)障礙患兒,隨機(jī)分為研究組和對(duì)照組各25例,研究組采用氟哌啶醇(0.025mg/kg起始劑量,根據(jù)癥狀緩解情況調(diào)整至最佳治療量,最大治療量2mg/d)聯(lián)合患兒及父母心理干預(yù)的治療措施,對(duì)照組采用單用氟哌啶醇藥物治療(劑量同前),治療8周后觀察其療效及安全性。結(jié)果50例抽動(dòng)障礙患兒中,男37例,女13例,64%(32/50)為學(xué)齡期兒童,主要表現(xiàn)為頻繁眨眼或(和)聳肩,72%(36/50)出現(xiàn)兩個(gè)以上部位的抽動(dòng)。研究組治療的總有效率達(dá)88%,顯著高于單純藥物治療組60%,二者具有統(tǒng)計(jì)學(xué)差異(χ2=5.049,P<0.05)。兩組患兒均無嚴(yán)重不良藥物反應(yīng)。結(jié)論小劑量氟哌啶醇治療兒童抽動(dòng)障礙起效快、療效好、有較好的安全性,同時(shí)患兒及父母的心理干預(yù)治療尤為重要,加強(qiáng)心理知識(shí)培訓(xùn),藥物治療的給與患兒及家屬早期的心理咨詢和干預(yù)處理,減輕家庭的沉重負(fù)擔(dān),獲得經(jīng)濟(jì)和社會(huì)效益。
兒科;抽動(dòng)障礙;心理干預(yù);臨床研究
[Abstract]Objective To explore the important role of psychological interventions for patients and their parents in assisting drug therapy to treat children with Tic disorder (TD). Methods A total of 50 cases of pediatric TD patients were collected and divided into two groups, study group and control group. All those patients received treatments at the pediatrics department of the First Affiliated Hospital of Xi’an Jiaotong University. As for patients in the study group, they received haloperidol (started with an initial dose of 0.025mg/kg; adjusted the dosage to the best therapeutic dose in accordance with the relief of clinical symptoms; the maximum dose was 2mg/d) combined with psychological interventions for patients and their parents. Patients in the control group received haloperidol (the same as the study group in dose). Therapeutic effects and safety of the preceding treatments were observed 8 weeks after their receiving those treatments. Results Among 50 cases of TD patients, 37 cases were male patients while 13 cases were female. Totally 64% (32/50) of the patients were children of school age. The main clinical manifestations were frequent winking or (and) shrugging. There were 72% (36/50) presenting twitching in two or more parts of body. The total effective rate reached 88% in the study group, which was significantly higher than that in the control group (60%). The preceding difference was of statistical significance (χ2=5.049,P<0.05). No children at both groups experienced severe adverse drug reactions. Conclusion Low dose of haloperidol takes effect quickly, has a good efficacy and relatively good safety in treating children with TD. Besides, psychological interventions for both patients and their parents are of great importance. Psychological knowledge training should be strengthened. In addition, it is necessary to carry out early psychological counseling and psychological interventions for patients and their family members when patients are receiving drug therapy. The preceding measures will help to reduce the heavy burden on the family and achieve economic and social benefits.
[Key words]department of pediatrics; Tic disorder (TD); psychological intervention; clinical study
抽動(dòng)障礙(Tic disorder,TD)抽動(dòng)障礙是一種于兒童和青少年時(shí)期起病的常見疾病,主要表現(xiàn)為快速的、突然的、反復(fù)的、不自主的一個(gè)或多個(gè)部位肌肉運(yùn)動(dòng)性抽動(dòng)或發(fā)聲性抽動(dòng)[1]。據(jù)臨床癥狀和病情長(zhǎng)短的不同,抽動(dòng)障礙分為短暫性TD、慢性TD和多發(fā)性抽動(dòng)癥(TS)。本病常反復(fù)性發(fā)作,病程、治療和康復(fù)過程較長(zhǎng),對(duì)兒童身心健康影響甚大,給家庭、學(xué)校、社會(huì)帶來不良影響,直接影響國(guó)家人口素質(zhì)。其發(fā)病機(jī)制尚未清楚。治療方面,目前以氟哌啶醇、利培酮、硫必利等經(jīng)典藥物為主要選擇,除此之外,心理行為治療、腦部神刺激、中醫(yī)針灸等治療也得到廣泛關(guān)注。本文將西安交通大學(xué)第一附屬醫(yī)院2015年5月至10月門診就診的50例患兒隨機(jī)分為研究組和對(duì)照組,分別給予不同的治療方法,觀察對(duì)比治療效果。
1.1研究對(duì)象
收集西安交通大學(xué)第一附屬醫(yī)院兒科門診就診的50例抽動(dòng)障礙患兒,男女不限,年齡4~14歲,所有研究對(duì)象均符合美國(guó)精神病學(xué)會(huì)的精神障礙診斷和統(tǒng)計(jì)手冊(cè)第4版(2000年)的TD診斷標(biāo)準(zhǔn)。排除精神發(fā)育遲滯、廣泛性發(fā)育障礙等精神和神經(jīng)系統(tǒng)疾病者,并排除嚴(yán)重軀體疾病和各種藥物副作用所導(dǎo)致的抽動(dòng)癥狀等。
1.2方法
應(yīng)用隨機(jī)對(duì)照研究方法設(shè)計(jì),將50例患兒隨機(jī)分為研究組25例,對(duì)照組25例,治療8周,評(píng)價(jià)其療效急藥物副反應(yīng)。
研究組治療方法:口服氟哌啶醇,每日0.025mg/kg起始劑量,根據(jù)癥狀緩解情況調(diào)整至最佳治療量,最大治療量2mg/d。同時(shí)給予父母及患兒的心理干預(yù)治療,具體如下:對(duì)患兒及家屬進(jìn)行抽動(dòng)障礙疾病相關(guān)知識(shí)講解和培訓(xùn),提高對(duì)抽動(dòng)障礙的認(rèn)識(shí);根據(jù)患兒的興趣愛好,每天參加一些輕松愉快的娛樂活動(dòng),鼓勵(lì)患兒積極面對(duì),找回自信;告誡家屬不要過分注意患兒的抽動(dòng)癥狀,杜絕打罵、責(zé)怪甚至體罰等管教方式;加強(qiáng)患兒家屬與學(xué)校老師之間的有效溝通,避免老師對(duì)患兒不正確的教育;營(yíng)造良好的家庭環(huán)境,避免父母在患兒面前爭(zhēng)吵。
對(duì)照組采用單用氟哌啶醇藥物治療,劑量同研究組。
1.3療效及藥物副反應(yīng)判定
采用耶魯抽動(dòng)癥整體嚴(yán)重度量表(YGTSS)在各治療期前后對(duì)研究對(duì)象進(jìn)行評(píng)分,得出YGTSS總分,按<25分為輕度,25~50分為中度,>50分為重度。以YGTSS減分率作為療效評(píng)定指標(biāo);減分率=(治療前總分-治療后總分)/治療前總分×100%。減分率>60%為顯效,減分率30%~59%為有效,減分率<29%為無效;治療總有效率=(顯效例數(shù)+有效例數(shù))/治療總例數(shù)×100%。
1.4統(tǒng)計(jì)學(xué)方法
2.1一般資料
兩組患兒年齡、性別、抽動(dòng)障礙類型的分布均無統(tǒng)計(jì)學(xué)差異(均P>0.05),所有患兒均完成8周治療觀察。見表1。
2.2兩組的療效比較
治療8周后,經(jīng)YGTSS量表評(píng)分計(jì)算出各組治療前后的減分率來判斷療效。研究組顯效5例,有效17例,無效3例,治療總有效率達(dá)88.00%;對(duì)照組顯效1例,有效14例,無效10例,治療總有效率60.00%。抽動(dòng)癥狀改善患兒共計(jì)37例。兩組差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。見表2。
表2研究組和對(duì)照組治療前后YGTSS總分及有效率的比較(n)
Table 2 Comparison of YGTSS total score and total effective rate before and after treatment between patients in the study group and control group(n)
2.3氟哌啶醇治療抽動(dòng)障礙安全性觀察
兩組研究對(duì)象均無1例出現(xiàn)嚴(yán)重不良反應(yīng)。對(duì)照組有8例患兒出現(xiàn)錐體外系反應(yīng),給予安坦對(duì)癥處理后均緩解;3例患兒出現(xiàn)口干、便秘;1例嗜睡。研究組6例患兒出現(xiàn)錐體外系反應(yīng),給予安坦對(duì)癥處理后均緩解;3例患兒出現(xiàn)口干、便秘;無嗜睡病例出現(xiàn)。兩組病例均無1例出現(xiàn)視物模糊、乏力、出汗、皮疹、粒細(xì)胞減少、抑郁等不良反應(yīng)。
3.1抽動(dòng)障礙患兒家長(zhǎng)及患兒心理狀態(tài)分析
有研究發(fā)現(xiàn)抽動(dòng)障礙患兒不僅造成機(jī)體生理性的損害,更會(huì)影響患兒及父母的心理健康,導(dǎo)致生活質(zhì)量嚴(yán)重下降[2]。本研究發(fā)現(xiàn)父母缺乏相關(guān)醫(yī)學(xué)專業(yè)知識(shí),長(zhǎng)期處于心理應(yīng)激狀態(tài),導(dǎo)致焦慮、抑郁等不良心理狀態(tài)。目前社會(huì)對(duì)本病關(guān)注甚少,患兒父母面臨如何向周圍人群解釋疾病的壓力,加上患兒父母潛在的羞恥感等都導(dǎo)致其出現(xiàn)焦慮、緊張等心理問題[3],更進(jìn)一步阻礙患兒的康復(fù)。
一項(xiàng)由全球21個(gè)國(guó)家參加的3 489名抽動(dòng)障礙患兒的綜合調(diào)查研究中發(fā)現(xiàn)在接受綜合治療的情況下,其中有大約19.4%的患兒在16歲以后仍然存在明顯的抽動(dòng)癥狀,而且沒有自愈性的有關(guān)報(bào)道[4]。由于病程長(zhǎng)、癥狀反復(fù)、行為猥褻、遭受別人恥笑、指責(zé),導(dǎo)致自身心理困擾、精神創(chuàng)傷,嚴(yán)重的自卑感等其它行為和情緒問題,影響學(xué)習(xí)、生活的質(zhì)量及正常身心的發(fā)展。
3.2心理干預(yù)及實(shí)施方法
3.2.1加強(qiáng)對(duì)家長(zhǎng)的基礎(chǔ)知識(shí)教育,對(duì)患兒家長(zhǎng)進(jìn)行心理輔導(dǎo)
本研究對(duì)患兒及家屬進(jìn)行抽動(dòng)障礙疾病相關(guān)知識(shí)講解和培訓(xùn),提高對(duì)抽動(dòng)障礙的認(rèn)識(shí);告誡家屬不要過分注意患兒的抽動(dòng)癥狀,杜絕打罵、責(zé)怪甚至體罰等管教方式;營(yíng)造良好的家庭環(huán)境,避免父母在患兒面前爭(zhēng)吵。通過以上干預(yù)措施及藥物治療后,研究組的患兒癥狀緩解率較對(duì)照組明顯提高,且治療有效率明顯高于對(duì)照組。故對(duì)于抽動(dòng)癥患兒,在藥物治療的同時(shí),更應(yīng)該關(guān)注患兒家屬的心理狀態(tài),認(rèn)真解答家長(zhǎng)的問題,打消家長(zhǎng)的顧慮,以免某些家長(zhǎng)對(duì)患兒進(jìn)行不正確引導(dǎo),加重患兒的抽動(dòng)發(fā)作。
3.2.2抽動(dòng)患兒的心理治療
首先幫助患兒正確認(rèn)識(shí)抽動(dòng)障礙,認(rèn)識(shí)到自己難以控制的癥狀是一種疾病,且抽動(dòng)癥狀的出現(xiàn)是暫時(shí)的,只要積極主動(dòng)地配合醫(yī)生的治療,是完全可以治好的,消除心理困擾,減少焦慮、抑郁情緒,建立康復(fù)的自信;其次根據(jù)患兒的興趣愛好,每天參加一些輕松愉快的娛樂活動(dòng),鼓勵(lì)患兒積極面對(duì),找回自信;加強(qiáng)患兒家屬與學(xué)校老師之間的有效溝通,避免老師對(duì)患兒不正確的教育。本研究通過對(duì)患兒進(jìn)行心理輔導(dǎo),使患兒抽動(dòng)癥狀明顯緩解,且明顯高于對(duì)照組。
綜上所述,抽動(dòng)障礙不僅對(duì)患兒產(chǎn)生生理上的影響,而且會(huì)對(duì)患兒及其家長(zhǎng)心理及生活方面產(chǎn)生負(fù)面影響。作為醫(yī)護(hù)工作者不僅要解除患兒的疾病引起的痛苦,更要關(guān)注患兒及家長(zhǎng)的心理問題,結(jié)合藥物治療,提高療效,提高患兒及其家庭的生活質(zhì)量,營(yíng)造和諧的醫(yī)療環(huán)境。
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[專業(yè)責(zé)任編輯:徐秀]
Clinical study on psychological interventions for pediatric patients with Tic disorder and their parents
FANG Xia-ling, GAO Wen-juan, CHEN Ning, LIU Xiao-hong, SHI Rui-ming
(Department of Pediatrics, First Affiliated Hospital of Xi’an Jiaotong University. Shaanxi Xi’an 710061, China)
2015-11-07
房夏玲(1976-),女,主管護(hù)師,主要從事兒童神經(jīng)系統(tǒng)疾病心理方面的護(hù)理管理工作。
史瑞明,副主任醫(yī)師。
10.3969/j.issn.1673-5293.2016.03.016
R749.94
A
1673-5293(2016)03-0329-03