Part 03. Psychologic Disorder
PART III. Psychologic disorder
Chapter 18. Assessment & Interviewing
18.1 The clinical interview
#
¸é´ãÀº ´ÜÁö history takingÀÌ ¾Æ´Ï¶ó
system review¿¡ ÇÊ¿äÇÑ °ÍÀ»À» ¾Ë±âÀ§ÇÑ È¯ÀÚÀÇ ±³Â÷ ½ÃÇèÀÌ´Ù
#
È¿°úÀûÀÎ ¸é´ãÀÌ µÇ±â À§ÇØ ¿ä±¸µÇ´Â °ÍÀº µ¿±âºÎ¿©, ±â¼ú,
Áö¼ÓÀûÀÎ °ü½É¾î¸° ³ë·ÂÀÌ´Ù
Time
;
Áß¿äÇÑ ±âÃÊ Á¤º¸ ȹµæ À§ÇØ Àû¾îµµ 30-40ºÐÀÌ ÇÊ¿ä
Setting
;
°³ÀÎÀÇ ºñ¹ÐÀº Áß¿äÇÏ´Ù
Æí¾ÈÇÑ Àå¼Ò°¡ ÇÊ¿äÇÏ´Ù
Goal
;
¸é´ãÀÇ ¸ñÀûÀ» ¼¼¿ì´Â °ÍÀÌ Áß¿ä
¸é´ãÀÇ È½¼ö ¹× ȯÀÚÀÇ conductionÀÌ ¸é´ãÀÇ ³»¿ë¿¡ ¿µÇâ¹Ìħ
Communication
;
Á¤º¸ ±³È¯ÀÇ 2°¡Áö ÇüÅÂ
;
content(message) : »ó´ë¹æ »çÀÌÀÇ ´Ü¾î ±³È¯
;
process : content°¡ ±³È¯µÇ´Â ¹æ¹ý(´ëÈÁß ºñ¾ð¾îÀûÀÎ
ºÎºÐÀÇ ±³È¯)
¡æ ¸ñ¼Ò¸®,
Ç¥Á¤, ÀÚ¼¼, ¿òÁ÷ÀÓ
¡æ ¼Ò¾Æ¿¡¼± ºñ¾ð¾îÀûÀÎ
¸éÀÌ Áß¿äÇÑ µ¥ Ç¥Á¤, ¸ñ¼Ò¸®
tone, µ¿ÀÛ, voice, ´Ù¸¥ ¹ÝÀÀ¿¡ ´ëÇÑ °üÂû ¹× ÇØ¼®ÀÇ ±â¼úÀÌ ÇÊ¿äÇÏ´Ù
Talking With Children
¨ç ³Ê¹« Ä£ÀýÇÑ Åµµ´Â ±Ý¹°
¨è ¾î¸°À̰¡ À¯Ä¡ÇÏ´Ù´Â ÀÇ»çÀÇ »ý°¢ÀÌ ¾Æµ¿¿¡°Ô Àü´ÞµÇÁö ¾Êµµ·Ï ÁÖÀÇÇÔ
¨é ¾î¸°À̰¡ ¿ô±âÁö ¾ÊÀº °æ¿ì ¾î¸°ÀÌÀÇ ¸»¿¡ ´ëÇØ ¿ô¾î¼´Â ¾ÈµÊ
¨ê ȯ¾Æ¸¦ ¿ô±â·Á°í ¾Ö¾²Áö ¸» °Í
¨ë ¾î¸°À̸¦ Àß ¾ËÁö ¸øÇÏ´Â °æ¿ì´Â ³î¸®Áö ¸» °Í
¨ì ¼Ó»èÀ̸ç Àλ縦 ÇÏ´Â °ÍÀÌ Á¢±Ù ÇÏ´Â µ¥ µµ¿òÀ» ÁÙ ¼ö ÀÖ´Ù
¨í 4-5¼¼ ÀÌ»óÀÇ ¾ÆÀÌ¿¡´Â ÀÇÇÐÀû ¹®Á¦¸¦ ±×¸²À¸·Î ¼³¸íÇÏ¸é µµ¿òÀÌ µÊ
¨î ¾î¸°À̰¡ µè´Â °÷¿¡¼ Á¦ 3ÀÚ¿¡°Ô º´¼¼¸¦ ¾ê±âÇÏÀÚ ¸» °Í
(discussÇϰíÀÚ ÇÒ ¶§´Â ¿¹¿Ü)
¨ï º´¿ø Ä¡·á¿¡ Àß ÀûÀÀ ¸øÇÏ¸é µÎ·Á¿öÇϰųª ºÎÁ¤Àû, µµÀüÀûÀÌ µÈ´Ù
Other Aspects Of Interview
¨ç ÇöÀç±îÁö ´ë´äÇÏÁö ¾Ê¾Ò´ø ¼ûÀº °ÆÁ¤À» ãÀ½
¨è ºÎ¸ð°¡ ¾ÆÀÌÀÇ ½ÇÁ¦ ¾ÆÇÄÀ» ´À³¢°Ô ÇÏ¸ç ºÎ¸ðÀÇ ¾ÆÀÌ¿¡ ´ëÇÑ ¼öÄ¡, ¸í¿¹È¸¼ÕµîÀ»
¹ß°ß
¨é ÀÇ»çÀÇ Áö½Ã¸¦ Àß µû¸£Áö ¾Ê´Â ºÎ¸ðÀÇ ÀÌÀ¯¸¦ Á¤È®È÷ °£ÆÄ
Other Sources For Assessment
Institution Or Agencies
Ãâ»ý±â·Ï ,Çб³±â·Ï,¾çÀ° ±â°üÀÇ ±â·ÏÀÌ µµ¿òÀÌ µÊ
Psychologic Testing
#
screen test
; Peabody picture vocabulary
test
; Denver developmental screen
test
; Thorpe developmental
Incentory
¡Ø82 4 Type Psychologic Test
¨ç perceptual motor
integrity
;
sensitive to ¡°organicity¡± or reflect structural or physiologic abormalities in
CNS
ex) Bender Gestalt
test
¨è intelligence test
ex) *Standford Binet, Weschler Intelligence
Scale for Children -Revised (WISC-R)
¡æ
10°¡Áö Ç׸ñÀ¸·Î Verbal &
performance IQ score¸¦ ¸Å±è
¨é achievement test
;
ÁÖ·Î Çб³¿¡¼ ½ÃÇà
ex) Wide Range
Achievement Test(WRAT)
¡æ
reading, spelling, mathmatics¿µ¿ªÀÇ ¼ºÃëµµ¸¦ ÃøÁ¤
¨ê projective test
;
indication of fantasy life, reality testing, personality characteristics
ex) *Rorschach test(ink blot), Thematic
Apperception test(TAT)
# Other assessment instrument
¨ç Achenbach child
behavior checkist
¡æ
child behavior problemÀÇ profileÁ¦°ø
¨è *The Nursing child Assessment feeding &
teaching scales(Barnard & Eyres)
¡æ ºÎ¸ðÀÇ ¾Æµ¿ÀÇ »óÈ£ °ü°è¿¡ ´ëÇÑ Á¤º¸ Á¦°ø
# child assessment schedule(CAS)
¡æ ¼Ò¾Æ ÁúȯÀÇ
standard classification interview
secting ¿¡ »ç¿ë
Psychologic Consultation
Ix ¨ç ¾Ö¸ÅÇϰųª ¼³¸íµÇÁö ¾Ê´Â ½Åü Áõ»óÀº ½ÇÁ¦·Î psychogenic
determinationÀ» °¡Áú ¼ö ÀÖ´Ù
¨è ÁÖ¿äÇÑ ±Þ¸¸¼º ÁúȯÀÌ ÀÖ´Â ¼Ò¾Æ¿¡¼
depressionÀÌ ÀÖ´Â Áö ¾Ë¾Æ º¸¾Æ¾ßÇÑ´Ù
¨é
chronic anxiety problem
¨ê underachievement
¨ë ½ÉÇÑ °ø°ÝÀûÀÎ ¾î·Á¿òÀÌ ÀÖÀ» °æ¿ì
Correlation Of Data
¸í¹éÇÑ Ãʱ⠸é´ã ÈÄ Á¶±â¿¡ Áø´ÜÀ» ³»·Á¼´Â ¾È µÇ¸ç ÀÚ±âÀÇ °¡Ä¡ ±âÁØÀ¸·Î ÆÇ´ÜÇØ¼µµ ¾È µÇ¸ç, °¡Á·µéÀÇ »çȹ®ÈÀûÀÎ
Á¤È²À¸·Î ÀÌ·ç¾î Á®¾ß ÇÑ´Ù
Referal
18.2 Psychgosocial Problems
¨ç disturbance in feelings : depression, anxiety
¨è disturbance in bodily functins : psychosomatic disorders
¨é disturbance in behavior : conductive cisturbance, passive-aggressive behavior
¨ê disturbance in performance : learning problem
# ÇൿÀÌ ¹ß´Þ»ó Á¤»ó, ºñÁ¤»óÀÇ ±¸ºÐÀº ³ªÀÌ, ºóµµ, °µµ, ±â´É Àå¾Ö Á¤µµ¿¡ µû¸¥´Ù
# *temper
tantrumÀº toddler¿¡¼´Â
Á¤»óÀûÀÎ negativismÀ¸·Î
Ç¥ÇöµÇ³ª 6»ì
ÀÌÈÄ¿¡´Â psychosocial
disturbance·Î ¿©°ÜÁø´Ù
Chapter 19. Psychiatric consideration of CNS injury
¨ç CNSÀÇ
infection, trauma, intoxication, À¯ÀüÀû, ´ë»çÀû Áúº´ ÈÄ Á¤½Å°úÀûÀÎ
¾î·Á¿òÀÌ ¹ß»ýÇÒ ¼ö ÀÖ´Ù
¨è psycosis´Â ¾Æµ¿±â¿¡ ÀÖ¾î¼ ³úº´º¯ÀÇ ÀüÇüÀûÀÎ °á°ú´Â ¾Æ´Ï´Ù
¨é rubella¾ÎÀº ¾Æµ¿¿¡¼
autism-like syndromeÀÌ º¸°í µÇ¾úÀ¸³ª autistic psychosis´Â ¾Æ¸¶µµ ƯÀÌȵÇÁö
¾ÊÀº genetic, physiologic, organic
factorÀÇ ÀÏÂ÷ÀûÀÎ °á°úÀÌ´Ù
¨ê 5-15¼¼»çÀÌ ³ú¿Ü»ó,
°£Áú ȯ¾Æ¿¡¼´Â psychiatic disorder°¡
5¹èÀÌ»ó ³ªÅ¸³²
¨ë mental retardation¿¡¼µµ
psychiatric disorderÀ§Çè¡è
¨ì ³ú¿°, ³ú¸·¿°À¸·Î ÀÎÇÑ psychiatric disorder´Â
3¼¼ ÀÌÇÏ¿¡¼ ¹ß»ý½Ã ³ªÁß¿¡ personality, behaviorÀå¾Ö(+)
¨í hydrocephalus &
motor deficitÀÖÀ» °æ¿ì, psychiatric disorderÀ§ÇèÀÌ
7¹è¡è
¸¸¼ºÀû Àå¾Ö¾Æ°¡ ÀûÀÀ ÇÏ´Â µ¥ °¡Àå Áß¿äÇÑ °ÍÀº ÀûÀÀÇÏ°í ´ëóÇÏ´Â ºÎ¸ðÀÇ ´É·ÂÀÌ´Ù
Chapter 20. Psychosomatic illness
#
Hallmark : significantly alters somatic function
#
¢¾3 Categories
¨ç Psychophysiologic disorders
: psychologic factor -->
development or recurrence of physical condition
*eg) DM, Rheumatoid arthritis, Asthma
¨è Somatoform disorder
: somatic complaints and/or
dysfunction without under conscious control
: no demonstrable organic
cause
: ¡ÚÁ¾·ù
¨Í
body dysmorphic disorder
¨Î
conversion disorder
¨Ï
hypochondriasis
¨Ð
somatization disorder
¨Ñ
somatoform pain disorder
¨é Factitious disorder
: somatic & psychological
complaints and/or dysfunction with under conscious control
: self-induced for secondary
gain
¡Ø97°´eg)
Munchansen by proxy syndrome
Conversion Disorder
;
loss or altertion of physical functioning /s demonstrable organic illness
;
adolescence or adulthood
;
*start suddenly
;
precipitating environmental event
;
*end abruptly after short duration
;
*Target site - voluntary musculature,
special sense organ
;
forms
- hysterical blindness,
paralysis, diplopia, gait disturbance, seizure
;
*nonspecific physical exam
;
children and families
- dramtic, hypochondriacal,
previous conversion episodes
Hypochondriasis
¨ç serious illness¿¡ ´ëÇÑ °øÆ÷°¡ ¼±ÇàÇÏ´Â somatization disorder
¨è conversion hysteria¿Í ÇÔ²² physiologic & emotional tensionÀ» ¹æÃâÇÏ´Â ´ëüÀûÀÎ route & mechanismÀ» Á¦°øÇÔ
¨é adolescence & early childhood¿¡ °¡Àå ÈçÇÔ
Munchausen By Proxy Syndrome
;
factitious disorder
;
*parents induce physical symptoms
;
a form of child abuse --> sometimes ending in death
;
¡Ú Warning Observation
¨ç
persistent or recurrent illness that cannot be explained
¨è
investigation results at variance with general health of the child
¨é
experienced dotors ; ±×·¯ÇÑ case¸¦ °áÄÚ º»ÀûÀÌ ¾ø´Ù°í ¸»ÇÔ
¨ê
symptoms ; not occur when the parent is away
¨ë
attentive primary caregiver ; refuse to leave the child alone in the hospital
for even a short time
¨ì
poorly tolerated treatments
¨í
a very rare disorder
¨î
primary caregiver´Â staff¸¸Å ±×µéÀÇ Àڳ࿡ ´ëÇØ °ÆÁ¤ÇÏÁö ¾ÊÀ½
¨ï
clinical syndromes that do not respond to appropriate treatment
#
Sx & Sg
¨ç
fractures
¨è
poisonings
¨é
persistent complaints of apnea
¨ê
unusual injuries
#
Tx
; abusing parent·ÎºÎÅÍ ¾ÆÀ̸¦ ¶¼¾î ³õ´Â °Í
Psychophysiologic Disorders
;
*insidious onset
;
chr. anxiety°¡ ÀÚÀ² ½Å°æ°èÀÇ ±â´ÉÀû ÀÌ»óÀ» ¾ß±âÇØ organ systemÀÇ ±¸Á¶Àû º¯È¸¦ ¾ß±âÇÔ
;
*eg) eczema, bronchial asthma,
ulcerative colitis, peptic ulcer, DM, rheumatoid arthritis
;
obsessiv & inhibited
;
no compelling evidence for specific personality characteristics
#
Management
¨ç ȯ¾ÆÀÇ Áõ»óÀº ÀǽÄÀûÀÎ Á¶ÀýÀÌ ¾Æ´Ï°í ÅëÁõ ¹× Áõ»óÀº ½ÇÁ¦ÀûÀÌ´Ù
¨è psychiatric asessment°¡ Ãʱ⿡ ½ÃÇàµÇ¾î¾ß
ÇÑ´Ù
¨é °¨Á¤ÀÇ ¿ªÇÒ°ú genesis¿¡ ´ëÇÑ ÀÌÇØ°¡ ½ÇÁ¦·Î È¿°úÀûÀÎ
interventionÀÌ ÀÌ·ç¾îÁö±â Àü¿¡ ºÎ¸ð¿¡ ÀÇÇØ ¼ö¿ëµÇ¾î Á®¾ß ÇÑ´Ù
¨ê ȯ¾ÆÀÇ psychotherapy¿Í
family counsellingÀÌ ÇÊ¿äÇÏ´Ù
¨ë Á¤½ÅÀûÀÎ Àå¾Ö¸¦ ÇÇÇϰí Á¤»óÀûÀÎ »îÀ» »ì±â À§ÇÏ¿© ¾ÆÀÌ¿Í °¡Á·ÀÇ µµ¿òÀÌ ÇÊ¿äÇÏ´Ù. °¡´ÉÇÑÇÑ Áúº´ÀÌ ³ªÀºÈÄ ÀÏÂï Çб³¿¡ ³ª°¡°í ¿©°¡ Ȱµ¿¿¡ Âü¿©Çϰí Á¤»óÀûÀÎ µ¿³â¹è °ü°è¸¦ °¡Áø´Ù
¨ì ÀÇ»ç´Â ȯ¾ÆÀÇ ºÎ¸ðÀÇ psychosomatic,
physical illnessÀ» ¸íÈ®È÷ ¾Ë°í Ä¡·á
Chapter 21.Vegetative Disorders
#
¡ÚClinical Manifestation
Eating disorder : rumination
disorder, pica, bulimia, anorexia nervosa
Elimination disorders :
encopresis, enuresis
Sleep disorders : dyssomnia,
parasomnia of adolescence
21.1 Rumination Disorder
;
À§Àå°ü ÁúȯÀ̳ª ¿À½É¾øÀÌ ¹Ýº¹ÀûÀÎ regurgitation¿¡ ÀÇÇÑ Ã¼Áß °¨¼Ò¸¦ Ư¡À¸·Î ÇÔ
;
fatal
;
*male, 3~14 mo
#
Type
- *psychogenic origin : Á¤»ó ¹ß´Þ¾Æ¿¡¼
ÀϾ
-
self-stimulating origin : Á¤½Å Áö¿¬ÀÌ ÀÖ´Â µíÇÑ ¾Æµ¿¿¡¼ ÁÖ·Î »ý±è
21.2 Pica
;
repeated or chronic ingestion of non-nutrient substnces
- plaster, charcoal, clay,
wool, ashes, paint, earth
*; 1-2¼¼¿¡
È£¹ß
- remit in childhood but
continue into adolescence and adulthood
;
¢¾predisposing factors
- mental retardation
- lack of parental
nurturing(psychologic and nutritional)
¡Ø97 Investigation
; pica *after the 2nd yr
#
Possible cause
¨çfamily
disorganization
¨èpoor
supervision
¨éaffectional
neglect
¡Ø97 Complication
; lead poisoning
; parasitic infection
¡ØDifferential Diagnosis
; autism, schizophrenia, kleine-levin syndrome
21.3 Enuresis(Bedwetting)
;
involuntary discharge of urine after the age at which bladder control
established
- after 5 yr(ÇÑ±ÛÆÇ)
Clinical Manifestation
¨ç persistent type(primary type)
; *75% of all enuretic child
¨è regressive type(secondary type)
; continent for at least 1 yr
; 50% of late school-aged
enuretic child
;
*male predominant
;
*7% for male, 3% for female at 5 yr
#
Regressive Type by *stressful
environmental events (move to a new home, marital conflict, birth of a sibling,
death in the family)
; intermittent, transitory
#
Possible Cause
- *inappropriate tolet training
- *coercive parents
- *chronic psychologic stress
- *social stress
- immigration
- socioeconomic disdvantage
- family psychopathologic
conditions
- immature development
- reduced bladder capacity
due to indequate training
- genetic predisposition
- organic pathologic
conditions
-->
physical exam & urinalysisÀ» ½ÃÇà
¢¾Treatment
¨ç cooperation of the child
;
chart the dry night
;
if one or more dry night, rewarding
-
small --> substantial
¨è
launder soiled bed clothes, pajamas in older children
¨é
no liquids after dinner time
¨ê
void before retiring
¨ë
waking the child repeatedly in only a few children
¨ì
discouraged punishment or humiliation
#
conditioning devices
- alarm
- *use in persistent refractory cases
- prerequisite consent of
child
#
¡ÚEffect
1) positive reinforcement
system ; 80-85%
2) conditioning devices ;
more than 90%
#
¡ÚImipramine(Tofranil)
; after 4hr
; 10-25mg/24hr before bedtime
;
works within 2 wks
; if not response, increased
to slowly 100mg/24hr
; *not exceed 2.5mg/kg/24hr
#
Àç¹ß ¹æÁö À§ÇØ Àû¾îµµ *5°³¿ù Ä¡·á
#
DDAVP : ÃÖ±Ù ÀÌ¿ë
21.4 Encopresis
; passage of feces into inappropriate places at any age after bowel control
¡Ø86 ; predominant male disorders
; 1% of school-aged children
; common low socioeconomic background
; *more
serious emotional disturbance than enuresis
Clinical Manifestation
1. primary ; persist from infancy onward
2. secondary ; regressive
# ¡Ø95°´
Asso. diseases
¨ç chronic consitipation
¨èfecal impaction
¨éoverflow incontinence
; ¡Ø95°´ may
progress to psychogenic megacolon
; unconscious anger, defiance
Treatment
; psychotherapeutic intervention
- fixed, disabling natureÀÎ °æ¿ì
; primary encopresis
- similar to enuresis
- initially enemas
-
¡Ø95°´ avoid chronic use of enemas &
laxatives
; secondary encopresis
- mineral oil & high fiber diet
; relieving constipation & removing impactions
; sitting on the toilet 10~15 min after each meal
; biofeedback
- train the anl sphincter muscle
21.5 Sleep disorder
; À¯º´À² 0.2-10%
Clinical Manifestation
# Cause
1. infant
; temperamental characteristic
; parental anxiety or strife
2. old children
; transient night-time fears (of burglars, noises, thunder, lightening, being kidnapped)
; separation anxiety
; fear for death
Narcolepsy
;
*frequent daytime naps &
cataplexy, sleep paralysis, hypnogogic hallucination
; genetic predisposition
; *starts in adolescence
; sleep laboratory studies ÇÊ¿ä
; conservative Tx
- daytime naps ; stimulants
- antidepressants for cataplexy
Nightmares
; 7-15%
; *anxiety dreams in REM sleep
;
*lucid quickly, remember content
of the dream
;
*more often in girl
;
*begin before 10 yr
; common in children with anxiety and affective disorders
¡Ø93 Night Terrors
;
*begin in preschool year
;
*arousal from stage4(non REM)sleep
- confused, disoriented
;
*signs of intense autonomic
acitivity
- labored breathing, dilated pupils, sweating, tachypnea, tachycardia
; peculiar visual phenomemon
;
*not recall content of the dream
; often self-limited
; related to a specific developmental conflict or traumatic events
; 2~5 %
;
*common in male
;
*familial pattern
;
*asso. /c febrile illness
;
*often somnambulism
Sleepwalking(=Somnambulism)
; during stage 3 or 4
; 10-15% of school-aged children
; normally remit by early adolescence
;
*asso. with noctural enuresis,
family Hx of somnambulism
; benign than adults
*; R/O temporal lobe epilepsy
¡Ø92 Treatment
; parental support, reassurance, encouragement
; calm, understanding
; regular, stated bedtime
; night light, permission to leave the child¡¯s door open
; avoid TV
; warm bath, a light snack, quiet affectionate moment
¡Ú Drug
- Diphenhydramine(Benadryl)
- Benzodizepines
- tricyclic antidepressants
Chapter 22. Habit Disorders
; tension-discharging phenomena
¡Ø84 Classification
¨ç head banging(¸Ó¸® ºÎ´èÈû)
¨è body rocking(¸öÀ» Èçµê)
¨é thumb sucking(¼Õ°¡¶ô »¡±â)
¨ê nail biting(¼ÕÅé ¹°¾î ¶â±â)
¨ë hair pulling(trichofillomania)
¨ì teeth grinding(bruxism : ÀÌ»¡ °¥±â)
¨í hitting or biting parts of one¡¯s own body
¨î body manipulations(¸ö ¸¸Áö±â)
¨ï repetitive vocalization(¹Ýº¹ÀûÀÎ ¹ß¼º)
¨ð breath holding
¨ñ swallowing air(aerophagia)
¨ò Tics
¨óstuffuring(¸»´õµë)
; tension-relieving activity·Î °£ÁÖµÇÁö´Â ¾ÊÀ½
# ¸ðµç ¼Ò¾Æ´Â ½À°üÀûÀÎ ¹Ýº¹µÇ´Â Çൿ, patternÀ» ³ªÅ¸³»³ª À°Ã¼Àû, Á¤¼Àû »çȸÀû ±â´ÉÀ» ¹æÇØÇÏ´Â Á¤µµ¿¡ µû¶ó Àå¾Ö·Î °£ÁֵȴÙ
# ½À°ü¼º ÁúȯÀº ¾Æµ¿ÀÌ Àáµé±â ÀüÀ̳ª È¥ÀÚ ÀÖÀ» ¶§, Áï »ç¶÷°úÀÇ Á¢ÃËÀ» ÅëÇÑ ÀÚ±ØÀ» ¹ÞÁö ¸øÇÏ°í ±× ´ë½Å¿¡ ÀÚ½ÅÀÌ ½º½º·Î À§¾ÈÀ» ÁÖ´Â ¹æ¹ýÀÇ ÇϳªÀÓ
# ÀÌ·± ¹Ýº¹ÀûÀÎ ÇൿÀº ³»ºÎ¹ßÀÛÀÇ ÇÑ Á¾·ù·Î ³ªÅ¸³ª¸ç ¾î¶² Á¾·ùÀÇ Á¤½ÅÀû À§¾ÈÀ» °¡Á®¿È
Teeth Grinding
; ¾ïÁ¦µÇÁö ¾Ê´Â ºÐ³ë, Àû°³½ÉÀ¸·Î ÀÎÇÑ tension¶§¹®¿¡ »ý±è
; Ä¡¾Æ ±³ÇÕ¿¡ ¹®Á¦¸¦ ¾ß±âÇÒ ¼ö ÀÖ´Ù
; ĪÂù°ú emotional support´Â À¯¿ëÇÏ´Ù
Thumb Sucking
; normal in early infncy
; teeth
- immature, interfere with normal alignment
; Tx
- interest in his or her well-being
- other forms of satisfaction
- praise & encouragement
¡Ø81,94 Tics
; repetitive movements of muscle groups
-
*face, neck, shoulders, trunk,
hands
; *discharges
of tension originating in emotional and physical states
; initially intentional --> nonintentional very quickly
; Sx
- lip smacking, grimacing, tongue thrusting, eye blinking, throat clearing
; ¡ÚDDx
- minor seizures
by no transient loss of consciousness or amnesia
- dyskinetic movements
by discontinuation during sleep, conscious control
; asso. /c psychiatric synd.
; follow encephalitis
; no physical antecedents
; *EEG
& cognitive testing - normal
Gilles de la Tourette syndrome
; 0.5/1.000 prior to 7 yr
; *multiple
tics, compulsive barking, grunting, shouting obscence words
; common in 1st degree relatives of patients
; *boys
3-4 times
; secondary behavioral, emotional, academic problem
; ¡ÚCause
- uncertain
- genetic, neurobiologic, psychologic, environmental factors
-
*dopaminergic action drugs
; laboratory studies - nonspecific
; EEG - nonspecific abnormal EEG
; lower scores on verbal subscales of psychometric tests
; ¢¾Drug Tx
- haloperidol (Haldol), Pimozide (Orap : dopamine antagonist), Clonidine (Catapres), Clonazepam (Klonopin), Carbamazepine (Tegretol)
; Px
- persists throughout life
- diminution symptoms in 1/2 or 2/3 of cases 10~15 yr after initial evaluation
¡Ø91 Stuttering(¸» ´õµë)
; begins atypical development during the learning of speech
; gradually, initially with repetition of consonants
; secondary compulsive, repetitive movements of muscle system
; 5% of children
; Px
- most spontaneously resolve
- 20% continue in adulthood
; *strong
family incidence
; more remit in girls
; Tx
- decreased emphasis
- consult to speech therapist : breath-control exercises, miniaturized metronome
Chapter 23. Anxiety Disorder
; anxiety, fearfulness, worryingÀº Á¤»ó ¼ºÀåÀÇ ÇÑ ºÎºÐÀÌ´Ù.
; disattached from specific situation or events, negatively ffect social interactions % development
--> pathologic
# Classification
¨ç separation anxoety disorder(ºÐ¸® ºÒ¾È Àå¾Ö)
¨è avoidant disorder(ȸÇÇ ºÒ¾È Àå¾Ö)
¨é overanxious disorder(°úÀ× ºÒ¾ÈÁõ)
¨ê obsessive compulsive disorder
¨ë phobia
¨ì post-traumatic stress disorder
¡æ¿¹ÃøÇÒ ¼ö ÀÖ´Â »óȲ°ú ¿¬°üµÈ anxietyÀÌ´Ù.
; normal anxiety
-
*initially 7-8 mo
; stranger reaction vs stranger anxiety
- stranger reaction
/ early develope
/ normal reation
- stranger anxiety
/ intense discomfort, psychologic & physiologic distress
/ heralds later problem related to attachement & separation
; preschool children
-
*specific fear about the dark,
animal, imaginary situation
; school children
-
*imaginary fears, fears of bodily
harm, real worries
# ¡ÚPossible origin of fears & phobias
; maternal anxiety
; genetic cause
; internal conflict not expressed
; learned within the context of the child¡¯s environment
; anxiety to persistent motor(neurologic) ¡°soft¡± signs
# phobia
; anxious only under specific conditions
¡Ø93 School Phobia
; ¿©·¯ ¿øÀÎÀ¸·Î ¾Æµ¿ÀÌ Çб³¿¡ Âü¼®ÇÏÁö ¾ÊÀ¸·Á ÇÔ(4-5¼¼ À̻󿡼)
; 1 ~ 2 %
; *Important cause
- hostile-dependent nature of relationship between mother and child
; *depression
- 70%, anxiety disorder - 60%, depression & anxiety - 50%
; Treatment
- Tx of underlying psychiatric problem
- family therapy
- parental management training
- liaison work with the child¡¯s school
Separation Anxiety Diorder
; *unrealistic
and persistent worries of possible harm befalling primary caregivers
; *reluctance
to go to school or to sleep alone
; persistent avoidance of being alone
; nightmares involving themes of separation
; lower socioeconomic class¿¡ ¸¹À½
; 3-4Çгâ±îÁö´Â Àß ³ªÅ¸³ªÁö ¾Ê´Ù°¡ ÈÞÀÏ, Áúº´À¸·Î Çб³ °á¼® ÈÄ Æ¯Â¡ÀûÀ¸·Î ³ªÅ¸³²
; Ä¡·á
- surpportive care-psychiatric theraphy
- ÀûÀýÇÑ ±³À° program ¶Ç´Â antidepressant, antianxiety drug »ç¿ë
Avoidant Disorder
; ³¸¼± »ç¶÷°ú Á¢Ã˽à ½ÉÇÑ °øÆ÷¸¦ ´À²¸ social isolationÀ» ¾ß±â
; ½ÇÁ¦·Î ÀÌ·± Áø´ÜÀº generalized anxiety pictureÀÇ ÇÑ ºÎºÐÀ̶ó°í »ý°¢ÇÏ´Â »ç¶÷µµ ÀÖ´Ù
Overanxios Disorder
. ¹Ì·¡, °ú°ÅÀÇ ÇàÀ§¿¡¼ ´É·Â¿¡ ´ëÇÑ °úµµÇÑ °ÆÁ¤ÀÌ ³ªÅ¸³²
. somatic compaintÀÇ È£¼Ò, ³»ÇâÀûÀÌ¸ç ±äÀåÀ» Ǫ´Âµ¥ ¾î·Á¿òÀ» ´À³¦
. onset : gradual, sudden
. ù° ¾ÆÀÌ¿¡¼ ¸¹°í ³²³àºñ´Â °°´Ù
. high socioeconomic class¿¡ ¼ ¸¹´Ù
. ´ë°³ »çÃá±â±îÁö´Â Áõ»óÀÌ ³ªÅ¸³ªÁö ¾Ê°í simple phobia, panic disorder·Î
¿ÀÁø µÇ±â ½Í´Ù
Obsessive-Compulsive Disorder
; ÀǽÄÀ» Ä§ÇØÇÏ´Â ¹ÝÁ·ÀûÀÎ »ý°¢ ¶Ñ´Â ÁÖ¾îÁø »óȲ¿¡ Àß ÀûÀÀ ¸øÇÏ´Â ¹Ýº¹ÀûÀÎ ÇàÀ§°¡ ³ªÅ¸³²
; obsessionÁß ÈçÇÑ °ÍÀº ½ÅüÀûÀÎ ¼Ò¸ð¿Í ºÐºñ¿Í °ü·ÃµÇ¸ç ºÒÇàÇÑ ÀÏ ¹ß»ý¿¡ ´ëÇÑ ºÒ¾ÈµîÀÌ´Ù
; ÈçÇÑ compulsionÀº ¼Õ¾Ä±â, Àá±ÝÀåÄ¡ÀÇ Áö¼ÓÀûÀÎ È®ÀÎ, touchingÀÌ´Ù
; ÀÌ·± »ý°¢, ÇൿÀº ÀǽÄÀûÀ̸ç Àڽſ¡°Ô Ä¿´Ù¶õ °íÅëÀ» ¾È°Ü ÁÜ
; anorexia nervosa, Gills ds, la tourette synd., epilepsy¿Í °ü·ÃµÉ ¼ö ÀÖ´Ù
; *PET
-
*increased metabolic activity in
the frontal lobe, basal ganglia
; Treatment
¨ç Çൿ¿ä¹ý(behavioral therapy)
¨è ¾à¹°¿ä¹ý - *clomipramine(anafranil),
fluoxetine(prozac), fluvoxamine
; dopamine, serotonineÀÌ °ü°èÇÑ´Ù´Â °¡¼³ÀÌ ÀÖ´Ù
Post-Traumatic Stress Disorder(PTSD)
Etiology
. À§ÇèÇÑ external trauma¹ÞÀº °æ¿ì
. »ó´çÇÑ stress¸¦ ¾ß±âÇÏ´Â Ä¡¸íÀûÀÎ »óȲÀÌ PTSD¾Æµ¿¿¡¼ ¼±ÇàÇÑ´Ù
. °¡Á·À̳ª Ä£ÇÑ Ä£±¸°¡ »ç°í·Î Á×´Â °ÍÀ» ¸ñ°ÝÇÑ ¼Ò¾Æ¿¡¼ PTSDÀÇ À§ÇèÀÌ ÀÖ´Ù
;
*more suffer in younger children
& females
Clinical Manifestation
. ¹Ýº¹ÀûÀÌ°í µ¹¹ßÀûÀΠȸ»ó, ÇØ·Î¿î »ç°Ç¿¡ ´ëÇÑ ²Þ, original trauma¸¦
»ó¡ÈÇÏ´Â »óȲÀÇ phychologic physiologic stress°¡ Ư¡ÀûÀ¸·Î ³ªÅ¸³²
# ¢¾Terr suggestion
; four long-term Sx complex
¨ç visualized or otherwise repeatedly perceived memories of traumatic event
¨è repetitive behavior
¨é traumatic-specific fears
¨ê changed attitudes about people, life & furture
; *Classification of childhood trauma
1) Type I trauma
- unanticipated, single event
- subsequently detailed memories, omens, misperception
2) Type II trauma
- ±Ø´ÜÀûÀÎ ¿ÜºÎ »ç°Ç¿¡ Áö¼ÓÀû ¶Ç´Â ¹Ýº¹ÀûÀ¸·Î ³ëÃâ
- developing denial, numbing
/ ÀÚ±âÃÖ¸é, ÇØ¸®, ½½ÇÄ, ºÐ³ë
- ¹Ýº¹ÀûÀÎ ¼ºÀû À°Ã¼Àû Çдë¿Í °ü·Ã
Treatment
; ¸ñÀû
¨ç ego & Çö½Ç °Ë»ç±â´ÉÀ» °È½Ã۰í
¨è ¾Æµ¿ÀÌ ¸ÅÀÏ »ý°¢³ª´Â °ÍÀ» ¿¹»óÇϰí ÀÌÇØÇϸç óġÇÏ´Â °ÍÀ» µµ¿ÍÁÖ°í
ÇöÀçÀÇ »ýȰ stess¿Í Áö³ª°£ trauma»çÀ̸¦ ±¸º°Çϵµ·Ï µµ¿ÍÁØ´Ù
. early intervention, psychotheraphy
. family theraphy, school consultation
. phamacotheraphy
Chapter 24. Mood Disorder
#
¡ÚThree major type of affective disorder
- Major Depression
- Dysthymic Disorder
- Bipolar disorder with alternating mania & depression
24.1. Major Depression
; ÃÖ±Ù¿¡´Â ¼Ò¾Æ³ª »çÃá±â¿¡µµ ¼ºÀο¡¼¿Í ¸¶Âù°¡Áö·Î ¿ì¿ïÁõÀÌ ¹ß»ýÇÑ´Ù°í ¾Ë·ÁÁ³´Ù.
Epidemiology
; *À¯º´À² 0.15-2%
; *¿©¾Æ>³²¾Æ
Etiology
; Genetic basis
- *À϶õ¼º ½Ö»ý¾Æ¿¡¼
ºóµµ ³ô´Ù
- *low functional level of norepinephrine & serotonin
/
*genetic markers
/ low urinary level of 3-methoxyhydroxyphenylglycol & 5-hydroxyindoleacetic acid
; Cognitive theory
- feelings of hopelessness, helplessness secondary to actual loss or perception of loss by individual
; Learning theory
- reasonable reinforcement ºÎÁ·À¸·Î ÀÎÇØ ÁÖÀ§ ȯ°æÀ¸·ÎºÎÅÍ depressionÀ» ¹è¿ò
Clinical Manifestation
Anaclitic Deprssion Of Infancy
; 6-7°³¿ù°æ ºÎ¸ð¿ÍÀÇ °Ý¸®µÇ¸é °Ý¸®¿¡ ´ëÇÑ Æ¯Â¡Àû ¼Ò°ß
- protest
/ crying, searching, panic-like behavior, hypermotility of both arms & legs
- despair
/ turns aways from everyone else
- apathy
/ hypotonic, inactive, exhibiting sad facial expression
Depressed School-Aged Children
; sad facial expression, easy tears, irritability, withdrawal from pleasurable interest, vegetative symptoms
# adolescents
; impulsivity, fatigue, depression, suicidal ideation
; *hallucination & delusion (cf. children : no deluson)
; hopelessness
; eposodes
-
*period of days or weeks
- somtimes suddenly secondary to a severe precipitant
; duration - variable
- 6 mo untreated
- sometimes 2~3 yr
# clinical course
; *40% of major depression
- relapse within 2yr
; *20% of major depression
-
*manic episode within 3-4yr
- ¢¾3 Predictors
¨ç depressive symptom cluster characterized by rapid onset, psychomotor retardation & mood congruent psychotic feature
¨è family Hx of bipolar illness or other affective illness
¨é induction of hypomania by antidepressant medication
Diagnosis
1) structured interview
. children's depression inventory
. children's depression scale
. Depression self-rating scale
2) biologic method
: dexamethasone(decadron) suppression test(DST)
3) sleep EEG
: inconclusive
Treatment
1) Phamacologic
¨ç tricyclic antidepressant
- imipramine (tofranil)
desipramine (nopramin)
¨è serotnin reutake blockers
- trazodone(desyrel)
flioxetine(prozac)
2)phycotherapy
3)play therapy
24.2 Dysthimic Disorder
; dysphoria more intermittent
- less intensive but more chronic, lasting up to several yers
Etiology
; genetic basis´Â ºÒÈ®½Ç
Clinical Manifestation
; ¡Úhallucination°ú delusionÀ» Á¦¿ÜÇϰí major depressionÀÇ ´Ù¸¥
Áõ»óÀÌ µ¿¹Ý
; *frequently
consequence of chronic disorders
-
*anorexia nervosa, somatization
disorder, anxiety disoder
; often begin in infancy
; affected children
- general emotional & social maladustment
; ´ë°³ ¾çÄ£ÀÇ depressive illneass hx(+)
; ¾ÆÀ̵éÀÌ ¹«·ÂÇÏ°í ¼öµ¿ÀûÀ̸ç ÀÇÁ¸ÀûÀ̰í, ¾µ¾µÇØ º¸ÀδÙ.
; major depressionº¸´Ù ¾çÈ£ÇØ º¸À̳ª ¸¸¼ºÀûÀ¸·Î Ä¡·áÇÏÁö ¾ÊÀ¸¸é ¾à 3³â°£ Áö¼Ó µÈ´Ù´Â º¸°í°¡ ÀÖ´Ù
Treatment
. antidepressant
. underlying ds°¡ À¯ÀÎÀÌ µÇ´Â °æ¿ì ¸ÕÀú Ä¡·áÇØ¾ß ÇÑ´Ù
24.3. Bipolar Disoder
1) alternating depression & mania or mania alone
2) ÀüÇüÀûÀ¸·Î 20-30´ë¿¡ Áõ»ó ¹ßÇö
3) Áúº´ Ãʱ⿡´Â manic episode °¡ ´õ ÈçÇÔ
4) Áõ»ó ¹ßÇöÀÌ ºü¸¦¼ö·Ï ÀÚ»ìÀÇ À§ÇèÀÌ ³ô°í episodeÀÇ ¹ß»ý ºóµµ°¡ ¸¹°í cyclingÀÇ ¼Óµµ°¡ »¡¶ó Áø´Ù
5) Treatment
- lithium carbonate
: Ç÷Áß³óµµ - Ãʱâ : 1.0-1.2mEq/L
À¯Áö¿ä¹ý:0.5-0.8mEq/L
- carbamazepine(tegretol)
CHAP 25. Suicide and Attempted Suicide
Epidemiology
1) 15-19 yr¿¡ high incidance
: increased abuse of alcohol
increased rates of depression adivorce
increased availabilty of firearm
increased in mobility
# facters influencing suicidal thought
; depression
; preoccupation with death
; general psychopathologic factor
# û¼Ò³â±â
;
*alcohol intoxicationÀÌ prominant factor
Clinical Manifastation
; 50-40% of completed suicides
-
*preceded by other suicide attempt
; depression, general psychopathologic factors
- related completed suicides
; ÀÚ»ìÀÇ 1/3ÀÌ ºÎ¸ð, ÇüÁ¦, ´Ù¸¥ Á÷°è ģô¿¡¼ suicidal behavior¸¦ º¸ÀÓ
; *firearms
-
*major method of death in
adolescent
; *jumping
from height
-
*¡ãcommon method in preadolescents
- followed by self-poisoning, hanging, stbbing, running into traffic
; ³²ÀÚ°¡ ¿©ÀÚº¸´Ù ÀÜÀÎÇÑ ¹æ¹ý ÀÌ¿ë
; children°ú adolescents¿Í Â÷ÀÌÁ¡
-
*adolescents´Â knowledge, fantasy, method¿¡
congruence(ÀÏÄ¡)À»
º¸ÀδÙ.
Treatment
Chapter 26. Disruptive Behavioral Disorders
; *lying,
impulssiveness, breath holding, defiance, temper tantrum
; 2-4yr
- need autonomy but no motor & social skill
-->
¡Øfrustration
& anger
--> above behaviors
Breath holding(È£ÈíÁ¤Áö ¹ßÀÛ)
; *24°³¿ùÀ̳»
; some children
-
*hold breath until loss of
consciousness
--> sometimes seizure but no risk of seizure disorders
; *ºÎ¸ð´Â
ÇൿÀ» ¹«½ÃÇϰí
±×³É ³»¹ö·Á
µÎµµ·Ï ÇÑ´Ù
- ¾Æµ¿ÀÇ ¹ßÀÛ¿¡ °ü½ÉÀ» µÎÁö ¸»°í ºÒ¾ÈÀ̳ª ÁÂÀý°¨À» ÀÌÇØÇÑ´Ù
Defiance, Oppositionalim, Temper tantrum(ºÐ³ë¹ßÀÛ)
; 18mo ~ 3 yr
; ¡ÚImportant thing
; response of parent or caregiver
- *teaching that out-of-control emotions are rasonable response to frustration
- advise to child
; if no acceptable
- give time & space
- time out or room restriction
Lying
# 2-4yr
;
*method of playing with language
; form of fantasy for children
# school-aged children
;
*¡ãoften
; child¡¯s attempt to avoid the pain of relative loss of selfesteem
# adolescents
; chronic lying
- often combined antisocial behavior
- underlying psychopthologic condition
Stealing
. ¹Ýº¹ÀûÀÎ ¶§¿¡¸¸ ¹®Á¦°¡ µÈ´Ù
. ÇзÉÀü°ú ÇзɱâÁß ¾î¸¥¿¡°Ô¼ Á¦´ë·Î º¸»ìÇËÀ» ¹ÞÁö ¸øÇß´Ù´Â °¨Á¤Àû °áÇ̶§¹®¿¡ Ãæµ¿ÀûÀ¸·Î ¹°°ÇÀ» ÈÉħ
. »çÃá±â, ºÎ¸ð¿¡ ´ëÇÑ °¥µî ¶§¹®¿¡ ¹ÝÇ×ÀûÀ¸·Î
. ºÎ¸ð´Â ¾Æµ¿ÀÌ ÈÉÄ£ ¹°°ÇÀ» µÂµ¹·Á Áְųª µ·À¸·Î º¸»óÇϵµ·Ï µµ¿Í ÁÖ¾î¾ß ÇÑ´Ù
Truancy & Run Away Behavior
; never developmentally appropriate
; represents disorganization within the home, developing personality problems, or both
; *normalÀÎ
°æ¿ì
-
*younger children¿¡¼ frustration or desire to get back at parents·Î
ÀÎÇÑ °æ¿ì
;
¿øÀÎ
- during the latency
/
abuse & neglect within home : *¡ãcommon
- in adolescents
/
disagreements with the parents, developing personality problems, abuse, neglect
all
Fire-Setting
Antisocial Behavior
Agressiion
; *¡ãserious
; ³²¾Æ¿¡¼´Â µ¶¼Áö¿¬, Áö´ÉÁö¿¬°ú ¿¬°ü
; °ø°ÝÀû ¾ð¾î´Â 2-4¼¼¿¡ ¸¹°í, 3¼¼°¡ Áö³ª¸é º¸º¹À» À§ÇÑ °ø°ÝÀû ÇൿÀÌ ¸¹¾ÆÁø´Ù.
; ¼Ò³â, Å«¾ÆÀÌ, °¡Á· ±¸¼º¿øÀÌ Å« ¾ÆÀ̰¡ more agressive
Passive Agressive Behavior
; ¼Ò¾Æ¿Í û¼Ò³â±â¿¡ ÈçÇÔ
; ²Ù¹°´ë°í °íÁýºÎ¸®°Å³ª ºÎ¸ðÀÇ ¸»À» µèÁö ¾ÊÀ½
Conduct Disorder
; several different antisocial behaviors
-
*stealing, lying, fire setting,
trauncy, property destruction, cruelty to animals, rape, use of weapon while
fighting, armed robbery, physical cruelty to others, reapeated attempts to run
away from home
; 6mo ÀÌ»ó Áö¼Ó½Ã
; Tx
- parent training methods
Oppositional Defiant Disorder
; *temper
tantrums, continuous arguing, defiance of rules, continual blaming of others,
angry and resentful affect, spiteful and vindictive behavior, frequent use of
obscene language
Chapter 27. Attention Deficit Hyperactivity disorder
¡Ø94 Ư¡
; poor ability to attend to a task
; motoric overactivity
; impulsivity
# For example
; fidgety
; difficult time remaining in their seats in school
; easily distracted
; difficult awaiting their turn
; impulsively blurt out answers to questions
; difficult following instructions and sustaining attention
; shift rapidly from one uncompleted activity to another
; talk excessively
; intrude on others
; not to listen to what is being said
; lose item regularly
; engage in physically dangerous activities without considering possible consequences
Etiology
¨ç *dopaminergic,
noradrenergic, serotonergic mechanism
; differ from normal children in terms of cognitive style, levels, types of arousal, response to rewrds
¨è abnormal PET(positron-emission tomography) scan
; reduced glucose metabolism in premotor & superior prefrontal cortex in adults
¨é genetic facter
Epidemiology
¨ç *4~6 times more in male
¨è *onset age ; ¨öÀÌ 4yrÀÌÀü
¨é À¯º´À² ; 1.5-4%
¨ê ADHD
developmental disorder
alcohol abuse
conduct dosoder
antisocial personality
--> common in 1st-degree relatives
¨ë disorder of cognitive impairment
¨ì *CNS, neulogic disease°¡ ¼±ÇàÀÎÀÚÀÏ ¼ö ÀÖ´Ù
Clinical Manifestation
; concurrent presence of conduct disorder, anxiety disorders, learning disabilities
- agression & fear, poor relationship with peers, academic difficulty, behavioral problems at school, reaction to authority
; events of the birth & delivary
; description of the child¡¯s temperament
- easy separation reaction, separation anxiety
; description of the child¡¯s behavior
- 18~13mo »çÀÌ¿¡ ¾ÆÀ̰¡ ±×¸¦ µ¹º¸´Â »ç¶÷°ú ½É¸®ÀûÀ¸·Î ºÐ¸® µÉ¶§
- 2~5yr¶§ ¾Æ±âÀÇ activity level
- ¡°colicky¡±, excessive temper tantrums, oppositionalism
# Initial identification
¨ç uncontrollable
¨è refuseing to sit still
¨é intruding into the space and activities of other children
¨ê boisterous & inattentive
¨ë refusing to follow instructions
¨ì provoke others to anger & rarely learn from their mistakes
; absent sign & symptom during physical examination
; ¡Úneurologic
¡°soft¡± sg(+)
- not diagnostic (Á¤»ó¾Æµ¿À̳ª ´Ù¸¥ Áúȯ¿¡¼µµ º¸Àϼö ÀÖ´Ù)
¨ç mixed hand preferance(¾ç¼Õ¾²±â)
¨è impaired balance(±ÕÇüÀå¾Ö)
¨é astereognosis(ÀÔü°¨°¢¼Ò½Ç)
¨ê dysdiadochokinesia(±³È£¿îµ¿ ºÒ´É)
Diagnosis And Differential Diagnosis
; lab studies : not helpful
; slow wave activity on EEG
- relevant unless neurologic disorder, epilepsy
; lower IQ
- uncertain
; some studies
- higher verbal scores than performance score in WISC-R
- lower score on attention-concentration subset
- lower educational level than expected age & IQ on peabody indivisual achievement test & wide range achievement test
¡Ø82 DDx
¨ç conduct disorder & learning diabilities
¨è sensory impairement(esp. auditory impairement)
¨é petit mal epilepsy
¨ê various medication(antipsycotics, anticonvulsant)
¨ë dysthymic, depressive disprder
¨ì Gilles dela Tourette syndrome
Treatment
Behavioral & Psychosocial Therapy
; *sturcture
to the child¡¯s environment
- ¾Æµ¿ÀÇ ÁÖÀ§È¯°æÀ» ±Ô°ÝÈ, ´Ü¼øÈ ½Ã۰í ÀÏÁ¤ÇÑ °èȹ¿¡ µû¶ó »ýȰÇÏ¸ç °úÀ× ¿îµ¿À̳ª ÀÚ±ØÀº ÇÇÇϵµ·Ï ÇÑ´Ù
; rewarded with praise
; avoids exciting television, rough, tumble games, long trips
; close communication between physician & school personnel is essential
; *behavior
therapy is more efficaous
¡ÚDrug medication
¨ç *methylphenidate(ricalin)
-
*¡ãcommonly used
-
*3¼¼À̻󿡼
»ç¿ë
- 5mg qd and then 4-6hr later
- increment 5mg/dose
- not exceed 2mg/kg/24hr
-
*¿ÀÈÄ 4½ÃÀÌÈÄ´Â Åõ¿©
±Ý±â
- 75-80% effective
- *2-3ÁÖ°£ º¹¿ëÈÄ efficacy°áÁ¤
¨è dextroamphetamine
- 0.2-0.5mg/kg, ½ÄÀü
- ¿ÀÈÄ 4½ÃÀÌÈÄ´Â Åõ¿© ±Ý±â
- 70-75%¿¡¼ effective
¨é magnesium pemoline
- initial 18.75mg
- 1ÁÖ¿¡ 1/2 tab Áõ·®
¡æ max 112.5mg/24hr
- 60-70% effective
- 2-3ÁÖ°£ º¹¿ëÈÄ efficacy°áÁ¤
- S/E - abnormal LFT
¨ê clonidine(catapres)
¨ë tricyclic antidepresant
- 60-70% effective
-
*side effect¶§¹®¿¡
Ãʱ⠾๰·Î´Â
»ç¿ëÇÏÁö ¾Ê´Â´Ù.
# ¡ÚS/E of
stimulant medication
; increased nervousness, jitteriness
; short term S/E
- anorexia, upper abdominal pain, difficulty with sleeping
-
*tics
/
*ADHD with tics : desipramineÀÌ
À¯¿ëÇÏÁö¸¸, sudden deathÀÇ
À§ÇèÀÌ ÀÖÀ¸¹Ç·Î
¿°µÎ¿¡ µÖ¾ß
ÇÑ´Ù.
; long term S/E
- HRÁõ°¡, growth suppresion
; °è¼ÓÀûÀÎ medicationÀÌ ÇÊ¿äÇÑÁö Æò°¡ Çϱâ À§ÇØ 1³âÁß Àû¾îµµ 2-3ÁÖ drug free period °¡Áö°Ô ÇÑ´Ù
Prognosis
1) »çÃá±â¿¡ °ÅÃÄ ¼ºÀαîÁö Áö¼Ó ÇÒ¼ö ÀÖ´Ù
2) *¼ºÀÎ alcoholism, sociopathy¿Í hysteria¿Í
°ü·ÃµÉ ¼ö
ÀÖ´Ù
3) ÃÖ±Ù ¿¬±¸, multiple theraphy(medication, psychotheraphy, parent counseling) Ä¡·áÇÑ ¾Æµ¿ÀÌ Ã»¼Ò³â±â¿¡ ¹üÁ˸¦ ´ú ÀúÁö¸¥´Ù°í ÇÑ´Ù
Chapter 28. Sexual Behavior & Its Variations
# Gender identity
; °¢ °³ÀÎÀÇ ³²¼º ¶Ç´Â ¿©¼ºÀ¸·Î¼ÀÇ ÀνÄ
# Gender role
; ³²¼ºÈ, ¿©¼ºÈ¿Í °ü·ÃµÃ ¹®ÈÁý´Ü¿¡¼ ÈçÈ÷ ÀνĵǾîÁö´Â ÇàÀ§
# *18mo¿¡ gender indentityȹµæ
; 18-30mo»çÀÌ¿¡ ¾Æµ¿Àº gender stability¸¦ ȹµæ
# 30mo ¿¡ gender constancy°¡ È®¸³, º¯È¿¡ ´ëÇÑ ÀúÇ×À» ³ªÅ¸³¿
# 2yr°æ ÀÚ½ÅÀÇ ½ÅüºÎÀ§ ¹× »ý»õ±ã ºÎÀ§ÀÇ À̸§À» ¹è¿ö¾ß ÇÑ´Ù
# *masturbationÀº social activity°¡ ¾Æ´Ï¸ç
È¥ÀÚ Ä§½Ç¿¡
ÀÖÀ» ¶§¿¡¸¸
±¹ÇѽÃÄÑ¾ß ÇÑ´Ù. ¶ÇÇÑ ¾ÆÀ̵éÀÇ sexual lifeÀÇ Á¤»óÀûÀÎ
Ãø¸éÀ̸ç ÁËÀǽÄÀ»
´À³¢°ÔÇØ¼´Â ¾ÈµÈ´Ù
# 10´ëµéÀÇ ½ÇÁ¦Àû ¶Ç´Â ÀÎ½ÄµÈ ¼ºÀû °æÇè ¹× ±×µéÀÇ °ÈµîÀÌ °³ÀÎÀÇ ±Ã±ØÀûÀÎ ¼ºÀû ¼±ÅÃÀ» Çϴµ¥ Áß¿äÇÏ´Ù
Transsexualism(¼ºÀûÀüȯ)
; *conviction
by a person biologically of one gender that he or she is a member of the other
gender
¨è ºÎ¿©µÈ ¼ºÀÌ ÀÏÂ÷Àû ÀÌÂ÷Àû ¼ºÀåÀÇ Á¦°Å¿¡ ³ë·ÂÇÑ´Ù
¨é ºóµµ : ³²-1/30000
¿©-1/100000
¨ê ´Ù¼öÀÇ ÀÌÁúº´¿¡ ÀÌȯµÈ ¾î¸¥¿¡¼ û¼Ò³â°ú °°ÀÌ gender identity disorder¸¦ °¡Áü
¨ë ÃÖ±ÙÀÇ psychologic condition°ú depressionÀÌ ¿øÀÎÀÌ µÇ±âµµ ÇÑ´Ù
¨ì ¼Ò³â¿¡¼ extreme feminity°¡ predisposing factor°¡ µÈ´Ù
¨í Ä¡·á : hormonal & surgical theraphy
dynamic & behavioral theraphy
Transvestism(º¹ÀåµµÂø) :
Cross-Dressing
; transiently in preschool boys
- dress up in their mother¡¯s clothing
; chronically in preschool & school-aged boys
- excited when dressed in women¡¯s clothing
; rarely in girl
; chronic cross dressingÀº underlying transsexualismÀ» ¹Ý¿µÇÒ ¼ö ÀÖ´Ù
; ÀÇ»ç´Â ¾Æµ¿ÀÇ gender identification& gender behaviorÀÇ ¿µ¿ª¿¡ ´ëÇØ Á¶»çÇØ º¸¾Æ¾ß ÇÔ
; Çзɱ⠳²¾ÆÀÇ 3-6% -+ °¡ ¹Ý´ëÀÇ ¼ºÃ³·³ ÇൿÇÏÁö¸¸
¿©¾ÆÀÇ10-12%-+
³²¾ÆÀÇ 2%¹Ì¸¸-+ ¸¸ÀÌ ¹Ý´ëÀÇ ¼ºÀÌ µÇ±â¸¦ ¿øÇÑ´Ù
¿©¾ÆÀÇ 2-4% -+
28.1 Gender Identity Disorder(GID)
. Çе¿±â ³²¾ÆÀÇ 28.8%-+°¡ 10°³ ÀÌ»óÀÇ gender atypical behavior¸¦ °¡Áü
¿©¾ÆÀÇ 36.6%-+
. ¹Ý´ëÀÇ ¼ºÀÌ µÇ·Á°í Áö¼ÓÀûÀÎ °í¹Î ¶Ç´Â ±¸¾îÁø ¼º±â ±¸Á¶¿¡ ´ëÇÑ °ÅºÎ°¨ÀÌ Æ¯Â¡
. transsexualism, transvestism, ¼Ò³âÀÇ ¿©¼ºÈ¸¦ Æ÷ÇÔ
1) Clinical menifeatation
. 4yr ÀÌÀü ¹ß»ý
. µ¿·á·Î ºÎÅÍ ¹èô´çÇÏ°í »çȸÀû ºÎÀûÀÀ
°á°úÀûÀ¸·Î ¿ì¿ïÁõÀ» °¡Áö°Ô µÊ
. ¹Ý ¼ö À̻󿡼 û¼Ò³â ¹× ¼ºÀα⿡ homosexualism°¡ ¹ß»ý
. behavior check list °Ë»ç»ó µ¿·á°£ ¾î·Á¿ò ¹× ºÐ¸®»óÅ¿¡ ¼ÓÇÔ
. À±¸®¹è°æ, Á¾±³, ±³À°¼öÁذú °ü·ÃµÇ¾î ÀÖÁö ¾Ê´Ù
2) treatment
- psychotheraphy
- phamachotheraphy
28.2 Homosexualism
. Àü¿¬·ÉÀÇ l5%¿¡¼ ¹ß»ý
1. Etiology
1) ¼ºÀû¹ß´ÞÀÌ º¯ÀÌ
2) ¹®Á¦ ÀÖ´Â ºÎ¸ð ÀڽŰ£ÀÇ °ü°è
3) »ý¹°ÇÐÀû ¿øÀÎ
¨ç dual mating sensor theory
: ¼ºÀû ÇàÀ§¸¦ Á¶ÀýÇϰí hyphothalamic area°¡ ÀÖ´Ù´Â ÀÌ·ÐÀ¸·Î androgen¾çÀûÀÎ Â÷ÀÌ·Î ¼³¸í
¨è Levay's recent finding
: homosexual°ú heterosexual menÀº ¼·Î hypothalamic structure¿Í site°¡ ´Ù¸£´Ù°í ÇÔ
¨é homosexual men¿¡¼ ant. commissure°¡ larger hamerµî marker°¡ ÀÖÀ½
2. femaleÀÇ 6% maleÀÇ 17%°¡ û¼Ò³â±â¿¡ homosexual experiance¸¦ °¡Áø´Ù°í ÃßÁ¤
3. ¨ç Hx taking½Ã sexual abuse case¸¦ Á¦¿ÜÇϰí´Â ºñ¹ÐÀÌ À¯ÁöµÇ¾î¾ß ÇÔ
¨è STD¿¡ ´ëÇÑ °Ë»ç ½ÃÇà
¨é HIV test ½Ç½Ã, hepatitis immunization ±ÇÀ¯
4. Tx
. ÁËÀǽÄÀ» À¯¹ßÇϴ ŵµ´Â Áö¾ç, ¾ÈÀüÇÔÀ» ´À³¢°Ô Çϱâ
. psychotheraphy
. Àǻ簡 ºÎ¸ðµé¿¡°Ô ºÎ¸ðÀÇ ¾î¶² model·Î¼ ±â¿©ÇÒ ¼ö ÀÖ¾î¾ß ÇÔ
. °¡Á·Áß °°Àº ¾ÆÀ̰¡ ÀÖ´Ù¸é ÇÔ²² Ä¡·á
Chapter 29. Psychosis in Childhood
29.1 Infantile Autism
; *30 °³¿ù
ÀÌÀü¿¡ ¹ßº´
; ¾ð¾îÀû ºñ¾ð¾îÀû ÀÇ»çÀü´Þ, »ó»ó·Â, È£ÇýÀû »çȸ»óÈ£ÀÛ¿ëÀÇ ÁúÀûÀÎ ¼Õ»ó
¡Ø97°´
Clinical Manifestation
1. ¾ð¾îÀå¾Ö
; °ÅÀÇ ¹ß´ÞµÇÁö ¾Ê°Å³ª ±«¼ºÀ» ¹ßÇÔ.
; ¾ð¾î ÀÌÀü ´Ü°èÀÎ ¿Ë¾Ë°Å¸², ȤÀº ¸ð¹æ ÇàÀ§µµ º¸ÀÌÁö ¾ÊÀ½
; speech pattern ÀÇ ÀÌ»ó
- echolalia
; ´ëÈ Áö¼Ó ´É·ÂÀÇ °á¿©
2. ´ëÀΰü°è Çü¼ºÀÇ Àå¾Ö
; ´« Á¢ÃËÀ̳ª ½ÅüÁ¢ÃËÀ» ÇÇÇÔ
; stranger anxietyµµ ¾øÀ½
3. º¯È¿¡ ´ëÇÑ ÀúÇ×, ¹Ýº¹Àû Çൿ
; µ¿ÀÏÇÑ °ÍÀ» ¿øÇÔ
; Èï¹Ì ¹üÀ§°¡ Á¼´Ù.
; visual scanning of hand & fingers, mouthing of objects, rubbing of surfaces
- heightened awareness & sensitivity to some stimuli
- but diminished response to pain, lack of startle response to sudden loudnoises
4. ±âŸ Áõ»ó
; 3/4 Áö´ÉÀúÇÏ, 50%À̻󿡼 ³úÆÄ¿Í CTÃÔ¿µ¿¡¼ ÀÌ»ó¼Ò°ßÀ» º¸À̰í, »ó´ç¼ö¿¡¼ °æ·ÃÀ» µ¿¹ÝÇÑ´Ù.
; ¶§¶§·Î Ź¿ùÇÑ Àç´ÉÀ» °¡Áú¼öµµ ÀÖ¾î ¼¼ºÎÀûÀÎ Áö´É°Ë»ç°¡ ¿äÇÔ.
; "theory of mind" °á¿© - ´Ù¸¥ »ç¶÷ÀÌ ´À³¢°í »ý°¢ÇÏ´Â °ÍÀ» ÀÌÇØ¸øÇÔ
¡Ø94 Epidemiology
; 3-4¸í/¸¸¸í
;³²>¿© (3-4:1)
; Àü½ÅÀû, °¨¿°¼º, ½Å°æ¼º ÁúȯÀÌ autistic sxÀ» ¾ß±â ½Ã۱⵵ ÇÑ´Ù.
; *seizure¿Í
°ü·Ã¼º ³ô´Ù.
Etiology
; À¯ÀüÀû ¿øÀÎ °¡´É¼º
- À϶õ¼º ½Ö»ý¾Æ 80% À̶õ¼º 20%
; ¿°»öü ÀÌ»ó °¡´É¼º
- *fragile X-syndrome
; *ºÎ¸ð¿¡
ÀÇÇØ »ý±âÁö
¾ÊÀ½
Treatment
; ¼º°øÀ²Àº ÇÑÁ¤Àû
; behavior therapy - ÆÄ±«Àû ÇൿÀº °¨¼Ò
; neuroleptics
; opiate antagonist
; ³îÀÌ¿Í ¾ð¾îÄ¡·á Æ÷ÇÔÇÑ Day treatment
; haloperidol 1-2mg
; antiepileptic drug
Prognosis
; speech°¡´ÉÇÑ ÀϺδ °øµ¿Ã¼ ¾È¿¡¼ »ç´Â °ÍÀÌ °¡´É (1/3 -1/5)
; ÀϺδ °ø°ø½Ã¼³ ³»¿¡ °è¼Ó ÀÖ¾î¾ß ÇÔ
29.2 Pervasive Developmental Disoredr (Àü¹ÝÀû ¹ß´Þ Àå¾Ö)
; ÀÚÆóÁõ°ú À¯»çÇÑ Áõ»óÀ» º¸À̳ª Áø´Ü ±âÁØ¿¡´Â ¹ÌÄ¡Áö ¸øÇÔ.
; *qualitative impairment in development of reciprocal social interaction, verbal, nonverbal communication
; diagnosed as schizoid personality disorder or Asperger syndrome
- higher functioning form of autism
; ¢¾Reactive
attachment disorder
- ¾çÀ° ¹æÀÓ°ú ¹«°ü½ÉÀ¸·Î ÀÎÇÑ °æÇè, ÀÚ±ØÀÇ °áÇÌ
--> ¾ÖÂøÇü¼º ¹®Á¦
- ÀÚÆóÁõ°ú À¯»çÇÑ Áõ»ó
29.3 Late Onset Psychosis
; ³ªÀÌµç ¾î¸°ÀÌÀÇ psychosis´Â ¾î¸¥°ú µ¿ÀÏÇÑ criteria
; *»çÃá±â
Àü¿¡´Â ¸Å¿ì
µå¹°´Ù.
; Type
- organic psychosis
- functional psychosis
; Schizophrenia
- »ç°íÀå¾Ö, ¸Á»ó, ȯ°¢ µî ¼ºÀο¡¼ º¼ ¼ö ÀÖ´Â °ÍÀº ¸ðµÎ º¸ÀδÙ.
-
*6¼¼ÀÌÈÄ
¾Æ¹«¶§³ª ¹ßº´, »çÃá±â¸¦ ÀüÈÄÇÏ¿©(11-13¼¼) ƯÈ÷
¸¹´Ù.
-
*Peak age : 17-20¼¼
; autism°úÀÇ DDx : ¨ç delusion ¨è hallucination ¨é late onset
¨ê high IQ score ¨ë ÀûÀº ÁÖ»ê±â ÇÕº´Áõ
; ¿¹ÈÄ ºÒ·®
29.4 Borderline Personality Disorder
Late onset psychosis ¾î¸°ÀÌ ´ëºÎºÐÀÌ °¡Áü
# Ư¡
1. °¨Á¤. ´ëÀΰü°è. sense of self °¡ ºÒ¾ÈÁ¤
ÀÚ»ì À§Çù, ÀÚ±âÇдë, Ãæµ¿Àû Çൿ
ÇൿÀå¾Ö°¡ Ç×»ó ³ªÅ¸³²
paranoid like thinking
2. ÀÚ½ÅÀ» ȯ°æÀÇ Á߽ɿ¡ µÎ°í ÇൿÇÏ·ÁÇϸç, ÀÌ ¿å±¸°¡ ÁÂÀýµÇ¸é °ø°ÝÀûÀÌ µÈ´Ù
# Ä¡·á: Áö¼ÓÀû ŵµ¿Í psychotherapy
# ¿Ü»ó ¹× Á¤½ÅÀû, À°Ã¼Àû ¸ð¿åÀÇ °á°ú·Î psychotic like behavior·Î ³ªÅ¸³¯ ¼ö ÀÖ´Ù.
Chapter 30. Psychologic Treatment of children & Adolescents
30.1 Illness & Death
# ÀÔ¿øÇÏ´Â °æ¿ì: 5-6¼¼ º¸´Ù ¾î¸° °æ¿ì ºÎ¸ð¿Í ÀÔ¿øÇؾß
# ¸¸¼ºÀû ÁßÁõ Áúº´
; 9¼¼±îÁö- Á×À½À» ¶°³ª´Â °ÍÀ¸·Î »ý°¢
; »çÃá±â±îÁö - ¾î¸¥µé¸¸Å öÇÐÀû °³³äÀ¸·Î »ý°¢
; Áúº´¿¡ ´ëÇØ Áú¹®ÇÒ ¶§ ÃæºÐÈ÷ ´ë´äÇØ ÁÖ¾î¾ß
; ÀÇ»ç´Â ºÎ¸ð¿Í ¾ÆÀ̰¡ °¨Á¤Àû Á¤½ÅÀû handicap ¿¡¼ ¹þ¾î³ªµµ·Ï µµ¿Í¾ßÇÑ´Ù.
# ±Þ¼ÓÈ÷ ¾ÇȵǴ Áúº´
; 9-10¼¼ ÀÌ»óÀÎ °æ¿ì¿¡´Â fatal illness¸¦ Ä¡·áÇÒ ¶§ Áø´Ü°ú ¿¹ÈÄ¿¡ ´ëÇØ Á¤È®È÷ À̾߱âÇØ ÁÖ¾î¾ß Çϸç, ±×·¯³ª Èñ¸ÁÀ» ¹ö¸®Áö ¾Êµµ·Ï
¢¾Á×À½¿¡ ´ëÇÑ
ÀÌÇØ
; À¯¾Æ±â¿¡´Â ½ÅüÀû ÅëÁõÀ̳ª °íÅë¿¡ ´ëÇÑ µÎ·Á¿ò
; Çзɱâ Àü¿¡´Â ºÎ¸ð¿ÍÀÇ À̺°(separation) ȤÀº ¹ö¸²¹ÞÀ½(rejections)À¸·Î ÇØ¼®
; 10¼¼°¡ µÇ¸é, Á×À½¿¡ ´ëÇÑ ºÒ°¡¿ª¼ºÀ» ÀÌÇØÇϰí, ±×¿¡µû¸¥ ºÒ¾È°ú °øÆ÷
30.2 Psychopharmachology
Neuroleptics
# hallucibnation, ¸Á»ó, »ç°íÀå¾Ö, ½ÉÇÑ agitation¿¡ »ç¿ë
# Ix
¨ç SPR disroder
¨è major affective disorder ¿¡ 2Â÷ÀûÀ¸·Î ¿Â
mood-congruent & mood-incongruent psychotic reaction
¨é autism (stereotype, withdrawal Sx, self-abuse)
¨ê Gilles de la Tourette syndrome
# Classification
; low potency
-
*chlorpromazine, thioridazine
- ³·Àº È¿°ú, ÀûÀº ÃßÁ¦¿Ü·Î Áõ»ó, sedativeÈ¿°ú, ¸¹Àº anticholinergic S/E
; mid pitency
- mesoridazine
- Ãßü¿Ü·Î Áõ»ó Áõ°¡
; high potency
-
*thiothixene, haloperidol
- Ãßü¿Ü·Î Áõ»ó ¸¹´Ù.
# ¡ÚSide
Effects
; Tardive dyskinesia
-
*¡ãworrisome side effect
ü°£, »çÁö, ¾ó±¼ ±ÙÀ°ÀÇ choreoathetoid movement
Àå±â°£ neuroleptics »ç¿ë½Ã 20-30%¿¡¼ ³ªÅ¸³²
¾à¹° »ç¿ëÁß¿¡ ¹ß»ý½Ã irreversible ÇÒ ¼ö ÀÖÀ½
¾à¹° Áß´ÜÈÄ withdrawal dyskinesia ´Â reversible
Tx: ¾à¹°Áß´Ü
¾à¹° »ç¿ë »çÀÌ¿¡ Àá±ñ¾¿ Áß´Ü (drug- free holiday)À¸·Î ¿¹¹æ
; Extrapyramidal Sx
- Parkinson - like syndrome
/ *akathisia, bradykinesis, torticolis, drooling, involuntary
hand movement
- dopaminergic blocking ±âÀü ¶§¹®¿¡, cholinergic system°úÀÇ ±ÕÇüÀÌ ÆÄ±«µÇ¾î ³ªÅ¸³²
- Tx : neuroleptics °¨·®, anticholinergic agent
; neuroleptic malignant syndrome
- rare but can be fatal
- °í¿°ú "lead-pipe" stiffenss
- Tx : Áï½Ã ¾à¹° Áß´Ü
; sedation
; anticholinergic side effects
Stimulant
# Ix : attention deficit hyperactivity disorder
Antidepressants & lithium carbonate
# Ix : affective disorder
# Tricyclic
; desmipramine
- heart block ¾ß±â ¡æ »ç¿ë ÀüÈÄ ECG check
; lithium (antimanic)
- hypothyroidism¾ß±â ¡æ »ç¿ëÀü °©»ó¼±. RFT. electrolyte°Ë»ç
¡ÚTable
30-1
Serotonin
reuptake blockers
# Á¾·ù : Fluoxetine (Prozac) Poroxetine (Paxil ¹Ý°¨±â ª°í S/E ÀûÀ½)
# Ix : °æÇÑ ¿ì¿ïÁõ, ºÒ¾È,°¹Ú
±âŸ
# clonidine - hyperactivety disorder
Tic (Gilles de la Tourette synd.)
# Pimozide - vocal & motor Tic, Gilles de la Tourette synd.
# carbamazepine - antiepileptic, mania, episodic dyscontrol synd.
30.3 Psychotherapy
1. play therapy
2. Dynamic therapy: ¾î¸°ÀÌÀÇ ¹®Á¦¸¦ psychologic motivationÀ¸·Î ÀÌÇØ
3. Behavior therapy
4. family therapy
5. parent management training: conduct disorder¿¡ ¾ÆÁÖ À¯¿ë
6. Group therapy
Chapter 31. Neurodevelopmental Dysfunction in the School-Aged Child
# Neurodevelopmental dysfunction : Çе¿±â ¾Æµ¿¿¡°Ô ÁÂÀý°ú ºÒ¾ÈÀ» ¾ß±â½ÃŰ´Â CNS Àå¾Ö
# Çе¿±â ¾Æµ¿ÀÇ 5-15%
¼ºÀû ÀúÇÏ -+
Çൿ °ï¶õ -+ ¿Í °ü·Ã
»çȸ ÀûÀÀÀÇ ¹®Á¦ -+
Etiology
´Ù¾çÇÑ ¿øÀÎ : ºÐ¸íÈ÷ ¹àÇôÁöÁö´Â ¾ÊÀ½
reading. spelling disability: genetic cause
learning. attention disorder: +- abn'l chromosome pattern
+- °æÇÑ ³³Áßµ¶, ¹Ýº¹Àû ÁßÀÌ¿°, ³ú¸·¿°, AIDS
+- IVH, read trauma
+- ÀúÃâ»ýüÁõ
+- °©»ó¼± ±â´É ÀÌ»ó
Clinical Manifestation
ÇнÀ´É·Â ÀúÇÏ ¾î¸°ÀÌ¿Í °ü·ÃÀÖ´Â 8°¡Áö ¿µ¿ª
Attention (ÁýÁß·Â)
# CNS°¡ Çൿ°ú ÇнÀÀ» Á¶ÀýÇϵµ·Ï ÇÏ´Â Á¶Àý ±âÀü
; affect learning, behavior, social interactions
# ¡ÚRegulation
of attention
1) CNS arousal, alertness level, mobilization of distribution of mental effort
; mental fatigue or overactivity
--> performance inconsistency
2) processing of incoming stimuli
; weakness of selective attention
3) output or production of work
; impulsivity
# *harbor
other forms of neurodevelopmental dysfunctions
# ADD ( Attention Deficit Disorder )
¨ç ÁýÁß·Â °á¿©·Î ¹®Á¦°¡ µÇ´Â ¾î¸°ÀÌ
¨è Çൿ°ú´Ù¿Í Ãæµ¿¼ºÀÌ Áö³ªÄ£ ¾î¸°ÀÌ
Dysfunction Of Memory (±â¾ï)
¨ç short-term memory Àå¾Ö : Á¤º¸ÀÇ Ã¹¹ø ±â·ÏÀÌ ¾î·Á¿ò
¼ö¾÷Áøµµ¸¦ µû¸¦ ¼ö ¾øÀ½
# dysfunction of active working memory
;
*trouble performing computations
in mathematics, problems with writing, difficulty in remembering, telling what
they have read
# dysfunction of consolidation information in long-term memory
# dysfunction of recalling
; painfully slow or imprecise
; difficutty of simultaneous recall
;
*especially disabling when
spelling, punctuation, capitalization, letter fromation, ides, vocabulary
# automatization(ÀÚµ¿È)ÀÇ Áö¿¬
ÀÛ¹®, ¼öÇй®Á¦ Ç®±â, ´Ü¾îÀÇ ¼ûÀº ¶æ Ç®±â µî¿¡ Àå¾Ö
Language
# problem with phonology (À½¼ºÇÐ)
; ¸»À» Á¤È®ÇÏ°Ô µèÁö ¸øÇÏ°í µ¶ÀÚÀûÀÎ À½¼ºÀ¸·Î ¹Ù²Þ
; ±ÛÀÚ¿Í ¼Ò¸®ÀÇ ¿¬°áÀ» Àß ¸øÇÔ
# Semantic (ÀǹÌ) deficit
; »õ·Î¿î ´Ü¾îÀÇ ½Àµæ°ú »ç¿ëÀÌ ¾î·Á¿ò
# receptive language dysfunction (ÀÌÇØ¾ð¾î Àå¾Ö)
; Çо÷ ¼ºÃë°¡ ¾î·Æ°í, ¸»·Î ¼³¸íÇÑ °ÍÀ» ÀÌÇØÇϰųª ÀÐÀº °ÍÀ» ÆÇ´ÜÇÏ±â ¾î·Æ´Ù
# expressive language dyusfunction (Ç¥Çö ¾ð¾î Àå¾Ö)
; Àǻ縦 Ç¥ÇöÇϴµ¥ Àå¾Ö
; ȯ°æÀû ¼Ò¶õ ½Ã¿¡ ³ªÅ¸³²
; ¸»´õµë
Visuospatial Ordering (½Ã°¢ °ø°£Àû Áö°¢)
# ¸ð¾ç. À§Ä¡. »ó´ëÀû Å©±â, ¿ø±Ù°ü°è, Çüź¸Á¸ µîÀÇ °ø°£Àû Ư¼º Æò°¡ÀÇ ´É·Â
# Àå¾Ö½Ã : ±Û Àдµ¥ ¹®Á¦ öÀÚ¹ý ¾àÈ
³ªÁß¿¡ Á¿챸ºÐ ¹× ¹Ì¼¼¿îµ¿ ´ë¿îµ¿ÀÇ Àå¾Ö
´Ù¸¥ ¹ß´Þ Àå¾Ö°¡ µ¿¹ÝµÇÁö ¾ÊÀº °æ¿ì´Â Áö¼ÓÀûÀ̰ųª ½ÉÇÑ Çо÷ Àå¾Ö´Â
³ªÅ¸³ªÁö ¾Ê´Â´Ù.
Temporal - Sequential Ordering (½Ã°£ Áú¼¿¡ ´ëÇÑ Áö°¢)
# ½Ã°£°ú ¼ø¼ÀÇ ÀÎ½Ä Àå¾Ö
¼ø¼¿¡ µû¶ó ¸»Çϱâ
Àϰú ½Ã°£ ÁöŰ±â ¹× Çб³ ±ÔÄ¢ ÀÏÁ¤À» µû¸£Áö ¸øÇÔ
öÀÚ¹ý, ȹý, ¼öÇÐÀÇ ¿¬»ê½Ä¿¡¼ ÀÏ·ÃÀÇ ¼ø¼¸¦ À¯ÁöÇÏÁö ¸øÇÔ
Neuromotor function (½Å°æ ¿îµ¿ ±â´É)
¨ç graphomotor fluency: ±Û¾²±â¿¡ Ư¼öÇÏ°Ô °ü°èµÈ ±â´É
Àå¾Ö ¨Í finger agnosia (¼öÁöÀÎÁö ºÒ´ÉÁõ) : ±Û¾µ¶§ ¼Õ°¡¶ô À§Ä¡¿¡ Àå¾Ö
¡æ ´«À» ±Û¿¡ °¡±îÀÌ ´ë°í ÀÖÀ½, Èûµé°Ô ¾´´Ù
¨Î graphomotor production deficit : °íµµ·Î Á¶ÈµÈ ±Û¾²±â ¿îµ¿¿¡
Àå¾Ö
¨Ï weakness of visualization : ±Û¾¾ ¾²´Â Áß¿¡ ³ªÅ¸³²
¨è gross motor coodination
°ø´øÁö±â¿Í ¹Þ±â, Ãã, üÁ¶, ¼ö¿µÀÇ Àå¾Ö
¡æ µûµ¹¸², ¿µî°¨
¨é fine motor coodination : gross motor action¿¡ visuospatial information
ÀÌ¿ëÀÌ ¾ÈµÊ
Higher-Order Cognition (°íµµÀÇ ÀÎÁö±â´É)
¨ç Ãß»óÀû °³³äÀÇ Çü¼º: ¼öÇÐ. °úÇÐ. »çȸ¿¡ ƯÈ÷ ¾àÇÔ. ¼ºÀûÀÌ ³·À½
¨è ¹®Á¦ ÇØ°á ´É·Â : °úÁ¦°¡ ÁÖ¾îÁ³À» ¶§ ÀûÀýÈ÷ °èȹ ¼¼¿ö ÇØ´äÀ» ±¸Çϴµ¥
¾î·Á¿ò
¨é âÁ¶·Â : ÀÚ½ÅÀÌ Çϱ⺸´Ù´Â ³²ÀÌ ¾î¶»°Ô Ç϶ó°í ¸»ÇØÁֱ⸦ ¿øÇÔ
¨ê ºñÆÇÀû »ç°í·Â : °´°üÀû ±âÁØÀ» »ç¿ëÇØ ºÐ¼®ÇÏ·Á´Â ´É·Â
¨ë º¹ÇÕÀû ÀÎÁö ´É·Â : ÀÚ½ÅÀÇ »ç°í³ª ÇнÀÀ» Æò°¡ÇÏ´Â ´É·Â
Àå¾Ö½Ã ½ÃÇè º¸°í¼ ÀÛ¼º°°Àº º¹ÀâÇÑ ÇнÀ °úÁ¤¿¡¼
È¿°úÀûÀÎ ¹æ¹ýÀ» ¸ð¸§
Social congnition (»çȸÀû ÀÎÁö)
»õ·Î¿î Àΰü°ü°è¸¦ Çü¼º À¯Áö
ºÐÀï¾øÀÌ »çȸÀû ³íÀïÀ» ÇØ°á
¿ø¸¸ÇÑ ´ëÀΰü°è À¯ÁöÇÏ´Â ´É·Â
ÀÚ½ÅÀÇ À̹ÌÁö¸¦ ¹ßÀü½ÃŰ´Â ±â¼ú
¹Ì¼÷ÇÑ °æ¿ì µûµ¹¸², ¾ð¾îÆø·Â, ³Æø, Á÷¼±ÀûÀÎ °ÅÀý, °ÅºÎÀÇ ¿©·¯ÇüŸ¦ º¸ÀÓ
Academic Effects
Readings
;
initially *poor phonological awareness
--> problem in forming association in memory between language sounds and combinations of letters
--> deficiencies at level of decoding individual words
; slow in sight vocabulary
;
¡Úreading disabilitesÀ» ÀÏÀ¸Å³
¼ö ÀÖ´Â
Àå¾Ö
- visuospatial dysfunction
/ trouble learning to read
/ rare
- weakness of temporal-sequential ordering
/ difficulty in breaking down words into their component sounds
- weakness of active working memory
öÀÚ¹ý
: memory Àå¾Ö
´Ü¾îÀÇ ÀÏÀÚ ¹è¿ÀÌ ¾î·Á¿î ¾î¸°ÀÌ : worst prognosis
3. ¾²±â : ÇнÀ°ú ÁýÁß¿¡ ¹®Á¦ÀÖ´Â ¾î¸°À̵éÀÌ ¾ÆÁÖ ²¨¸®´Â °Í
graphomotor Àå¾Ö½Ã ¾ÆÁÖ Èûµé¾îÇÔ
4. ¼öÇÐ: º¸Åë 6Çг⿡¼ 6°³¿ù ÀÌ»ó óÁö´Â ¾ÆÀÌ´Â ¾øÀ½ ¡æ ±Øº¹°¡´É
½É°¢ÇÑ Áö¿¬½Ã ±Øº¹ ºÒ°¡´É
+- high-order cognition weakness: ºñÀ², percentage, °ø½Ä µîÀÇ »ê¼úÀÇ °³³äÀ»
| ÀâÁö ¸øÇÔ
+- memory weakness : ±ä ¹®Á¦¸¦ Ç® ¶§ ÀûÀýÇÑ ¼ø¼¸¦ ±â¾ïÇÏÁö ¸øÇÔ
+- Language Àå¾Ö : ¼±»ý´ÔÀÇ ¸»°³³äÀ» ¸ø¾Ë¾ÆµéÀ½
+- Attention deficit
+- visualization (¶°¿Ã¸®±â) ±âÇÏÇÐÀû ¸ð¾çÀ̳ª ºñÀ²À» ¸¶À½¿¡ ¶°¿Ã¸®Áö ¸øÇÔ
5. Content Area Subjects
NDD ¾ÆÀÌ´Â ³ÐÀº ¹üÀ§ÀÇ ÇнÀ ºÐ¾ß¿¡¼ ¾î·Á¿òÀ» °æÇè
Nonacademic Impacts
attention Àå¾Ö°¡ ÀÖÀ» ¶§´Â Çб³³ª Áý¿¡¼ °ø°ÝÀûÀÌ°í ÆÄ±«ÀûÀÌ´Ù.
ÀϺκп¡¼´Â °úµµÇÑ ¼öÇàºÒ¾ÈÀ̳ª ¿ì¿ïÁõÀÌ ³ªÅ¸³ª¸ç ¸¸¼ºÇÇ·Î, Èï¹Ì»ó½Ç,
ºñ°üÁÖÀÇ µîÀÌ ³ªÅ¸³´Ù.
Diagnosis (Assessment)
# neurodevelopmental dysfunctionÀº ¼ºÃëÀúÇÏÀÇ ³ÐÀº ¹üÀ§¿¡ ¿µÇâÀ» ÁÖ´Â ¿øÀÎÀÌ µÇ¹Ç·Î ¿©·¯ºÐ¾ß¿¡ °ÉÄ£ Á¶»ç¸¦ ÇØ¾ßÇÔ
team: ¼Ò¾Æ°ú ÀÇ»ç, ½É¸®ÇÐÀÚ, Á¤½Å°ú ÀÇ»ç, ½É¸®±³À° Àü¹®°¡, ¾ð¾îº´¸®ÇÐÀÚ, Ãë¾÷Ä¡·á»ç, ½Å°æ°ú ÀÇ»ç, »çȸ »ç¾÷°¡
# Attention. memory °°Àº ´Ù¾çÇÑ meurodevelopmental function À» °Ë»çÇÏ´Â À¯¿ëÇÑ ¹æ¹ý
Á÷Á¢ÀûÀÎ Çൿ°üÂû°ú ÁßÇÑ ½Å°æÀû ÁöÇ¥µéÀ» Æò°¡
+- PEET
+- PEER
+- PEEX2
+- PEERAMID2
# ANSER system Questionnairs:
Áú¹®¿¡ ´ë´äÇÏ´Â ¹æ½ÄÀ¸·Î Á¤º¸¼öÁýÇÏ´Â ¹æ¹ý
ÇൿÀûÀÀÀÇ ÃֽŠÁ¤º¸, Çй®Àû ¼öÇàÀÇ ¹æ½Ä, Ưº°ÇÑ ¹ß´Þ Àå¾Ö¿Í °ü·ÃµÈ Ư¡À»
Á¦°øÇÒ ¼ö ÀÖ´Â °Ë»ç¹ý
# Ç¥ÁØÈµÈ behavioral checklist
+- Yale child Behavioral Inventory
+- Connors Questionnaire
+- Achenbach Child Behavioral checklist
# ±âŸ +- Áö´É °Ë»ç (IQ´Â º°·Î µµ¿ò ¾ÈµÊ)
+- Á¤½Å±³À° °Ë»ç
Treatment
´ëºÎºÐÀÇ ¾î¸°ÀÌ¿¡¼ ¸î°¡Áö ¹æ¹ýÀÌ ÇÊ¿ä
1. Denystification(°è¸ù) : Àå¾ÖÀÇ º»Áú°ú ¾Æµ¿ÀÇ ÀåÁ¡À» ¾Ë±â½¬¿î ¾ð¾î·Î ¼³¸í
2. Bypass Strategies(¿ìȸÀü·«) : ¼öÇн𣿡 °è»ê±â »ç¿ë
word processor »ç¿ë, ±Û´ë½Å ±¸µÎ·Î º¸°í, ¼±»ý´Ô ±Ùó¿¡ ¾ÉÇô ¼ö¾÷ ¹Þµµ·Ï
3. Remediation of skills (±³Á¤¼ú) : °³ÀÎÁöµµ program
4. Developmental therapy (¹ß´Þ Ä¡·á) : È¿°ú¿¡ ´ëÇØ ³í¶õÀÌ ÀÖÀ¸³ª ³Î¸® »ç¿ë
+-speech. language pathologist:
| Ãë¾÷ Ä¡·á»ç: ¾²±â³ª gross motor Àå¾Ö½ÃÀÇ Ä¡·á
| social skill training: ¼Ò±×·ì ¼ö¾÷
+-cognitive behavioral therapy : ÀÚ½ÅÀÇ meurodevelopmental disorder¿¡ ´ëÇØ
¹è¿îÈÄ ¾àÇÑ ºÎºÐÀ» Ư¼ö ¿îµ¿À¸·Î °È
5. curriculum modification (±³°ú°úÁ¤ º¯°æ) : ¿Ü±¹¾î, ¼öÇÐ, °úÇÐ °ú¸ñ ¼±ÅÃ
6. strengthening of strength (ÀåÁ¡ÀÇ °È) : Èï¹Ì, °¡´É¼º, Àç´É µîÀ» »ì·ÁÁÖ´Â °ÍÀÌ ºÎÁ·À» ±³Á¤ÇÏ´Â °Í ¸¸Å Áß¿ä
7. ȯ¾Æ¿Í °¡Á· »ó´ã
8. Advocacy(º¯È£, ÁöÁö)
À¯±Þ ¹× »çȸÀû ±¼¿åÀÇ ¿øÀÎÀ» Á¦°ÅÇϱâ À§ÇÑ Àå¾Ö ¾Æµ¿¿¡ ´ëÇÑ º¯È£ ¹× ÁöÁö°¡
ÇÊ¿äÇÏ´Ù
9. medication
# stimulant medication : attention deficit Ä¡·á, ´Ù¸¥ ±â´É °¨¼Ò¿Í µ¿¹ÝµÈ °æ¿ì°¡
¸¹À¸¹Ç·Î Á¾±³½ÃµÇ¾î¼± ¾ÈµÊ
+- methylphendate (Ritalin)
+- dextroamphetamine(Dexedrine)
+- pemoline (Cylert)
# Antidepressant
# ¾à¹° º¹¿ëÇÏ´Â ¼Ò¾Æ´Â ±ÔÄ¢Àû follow-up
ÀÚ½ÅÀ» ½º½º·Î Á¶ÀýÇÒ ¼ö ÀÖµµ·Ï interval À» µÐ´Ù
10. Longitudinal case management
ÇнÀ±â°£µ¿¾È Áö¼ÓÀûÀÎ follow up °ú °³º°ÀûÀÌ°í °´°üÀûÀÎ Ãæ°í°¡ ÇÊ¿ä