注意力缺失過動症執行功能與認知行為親子治療團體之關聯探討

The Association between Executive Function of ADHD and Cognitive-Behavioral Therapy in Parent-Child Group

陳盈如(Ying-Ru Chern)

指導教授 ： 黃惠玲

高雄醫學大學/健康科學院/行為科學研究所/碩士(2005年)

摘要

注意力缺失/過動疾患 (ADHD) 是兒童精神科常見的疾患，過去認為其主要的問題為注意力不良、過動衝動，此疾患深受神經生理因素的影響。近年來，研究普遍認為ADHD兒童的核心問題為「行為抑制的缺陷」；而在1997年Barkley學者提出執行功能混合模式 (A hybrid model of executive function)，模式中指出行為抑制缺陷間接地干擾了ADHD兒童目標導向動作行為的控制，此顯示這些兒童在自我調節上的困難，所以表現出持續注意力困難、過動衝動、無法延宕滿足、無法順從指示等行為。很多證據顯示，此疾患與大腦前額葉皮質發展功能的異常有關，有些兒童因而展現出高層語言上的問題，或內在語言發展的遲緩，以至於無法獲得適應性的執行技巧。一般而言，認知行為治療中問題解決策略的教導，可視為一種執行功能技巧的訓練，教導中實際上是在強化兒童執行階段的過程及有效性。
本研究主要目的有三：（1）以Barkley的「執行功能混合模式」分析ADHD認知行為親子治療團體方案中所訓練的執行技巧 (方案包含主軸課程及輔助課程)，並探討方案課程難易度順序安排是否適當；（2）以「技巧開始訓練節次」及「訓練次數」為主，初步區分訓練技巧之難易度；（3）探討團體方案的介入是否能改善ADHD兒童在家庭和學校情境下表現的症狀或問題行為。研究對象為18位學齡期ADHD兒童（小學二年級到五年級），團體進行方式採親子共同參與，每週一次，共22次團體，包含3次父母團體及19次親子團體；利用干擾行為疾患量表-家長版/老師版、兒童注意力問題量表、家庭及學校情境問卷，監控團體介入的療效。
研究結果發現：（1）團體方案主軸課程和輔助課程在技巧訓練上相互補足，評分者間一致信度為0.8-1；（2）團體方案後面的應用主題，相較於方案前面的問題解決主題，訓練技巧的數量呈現遞增的現象；但在應用主題間，則依不同主題不同能力項目的訓練而有增減；（3）親子治療團體介入後第19週開始，ADHD兒童在家的過動行為、情境困擾總分、平均嚴重度上有顯著改善，至團體最後治療效果仍維持，且注意力不良、對立反抗行為亦產生顯著性改善；（4）親子治療團體介入，對ADHD兒童在校症狀行為及其他問題行為未達顯著性改善，但團體後期多數指標分數有下降現象；此顯示團體訓練技巧類化至學校情境的效果有限；（5）方案中負向管理主題訓練前後，ADHD兒童在家的注意力不良、過動衝動、對立反抗行為有顯著改善，此顯示負向想法轉換對ADHD兒童症狀行為的改變是一個重要的因素。回歸Barkley執行功能模式來看，推論自我情緒/動機/激發狀態調節與動作控制之間存在相當的關聯強度。本研究結果與發現，提供給未來學術研究或對ADHD兒童治療的方向。

關鍵字

親子 ； 學齡期兒童 ； 執行技巧訓練 ； 注意力缺失/過動疾患 ； 執行功能 ； 認知行為取向

並列摘要

Attention-Deficit Hyperactivity Disorder (ADHD) is a common disorder of child psychiatry. Initially, problems with inattention and hyperactivity-impulsivity were thought to be the major features of this disorder, resulting from neurobiological factors. More recently, researchers theorizing on ADHD emphasized “a deficit in behavioral inhibition” as the central impairment of the disorder. In keeping with this trend, Barkley proposed “A hybrid model of executive function” in 1977. The model indicated that inhibitory deficit indirectly disrupts the control of goal-directed motor behavior by its influence on executive function, demonstrating the difficulty of self-regulation. Therefore, children with ADHD have more difficulties in sustained attention, hyperactivity-impulsivity, deferring gratification, restricting their behavior in conformance with instruction. Increasing evidence suggests that ADHD is associated with abnormalities in function of the prefrontal cortex, it could be the failure to acquire higher level language or to result in a delay of inner speech. Accordingly, ADHD may fail to adaptively develop the executive skill. Generally speaking, teaching problem-solving strategies in cognitive-behavioral therapy (CBT) , as well as training executive function, essentially strengthens the process of executive stage and its efficiency.
The aims of present study were: (1) to analyze skills of the CBT program in parent-child group according to Barkley’s hybrid model of executive function (including chief and additional curriculum), and to discuss whether the order of sessions have an appropriate arrangement on the program; (2) to preliminarily discriminate the complexities of skills which were based on the beginning session of training and the frequency of training; (3) to evaluate the effectiveness of CBT program for school-aged children with ADHD. A 22-week CBT program implemented for 18 children diagnosed with ADHD and their parents. The child-based intervention comprised 19 weekly sessions focusing on target skills in solving problems, whereas the 3-week parent group focused on teaching parents to help their child learn skills. The rating scales including Disruptive Behavior Disorder Rating Scale-Parent/Teacher Form, the Child Attention Problems Scale, Home/School Situations Questionnaire, were used to assess and to monitor treatment effect.
The results indicated that: (1) interraterreliability ranged from 0.8 to 1 indicating that training executive skills in the chief and additional program were matched reciprocally; (2) the number of training skills in posterior applied program were increasing than the prior of program, but among applied sessions are inconsistency because different themes had emphasized distinctly; (3) from 19th to 21st week, there were significant improvements on the measures of hyperactivity, behavioral severity, and total score of problem situations to the home setting. Until 21st week, significant treatment effect were obtained on inattention, oppositional-defiant behavior; (4) there were no significant improvement to the school setting, but virtually most measures were fewer problems than baseline. Limited evidence was found for generalization of treatment gains to classroom; (5) children who were assessed at pre- and post- negative emotion management training, and there were significant efficacy on inattention, hyperactivity, oppositional-defiant behavior at home. The finding demonstrated that shift of negative thought is an important component to affect core problems. Regress to consider the Barkley’s model, it exhibited that self-regulation of affect/motivation/arousal contributes a lot of degree to the motor control in the model. The results of this study can offer the reference to future research and a direction of clinical intervention for children with ADHD.

並列關鍵字

patent-child ； school-aged children ； executive skill ； executive function ； cognitive-behavioral approach ； Attention-Deficit/Hyperactivity Disorder

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