教師在兒童抑郁癥處理過(guò)程中的作用

1、,教師在兒童抑郁癥處理過(guò)程中的作用A Teacher's Role in Treatment of Childhood Depression,關(guān)于童年抑郁的教師須知,Until recently, the very existence of depression in children was questioned. Today, it is estimated that 20 percent of the school-ag

2、e population manifests some symptoms of depression 直到晚近，兒童抑郁究竟是否存在仍然是個(gè)問(wèn)題。但是如今據(jù)估計(jì)有20%的學(xué)齡兒童表現(xiàn)出某些抑郁癥狀。,The “Who” of Childhood Depression “哪些人”患兒童抑郁癥,Korup (1985) found that 10 percent of a sample of 226 six- to twelve-yea

3、r-old students exhibited symptoms of depression. Leftkowitz and Tesiny (1985), in a study of 3,020 elementary school students, reported a 5.2 per-cent prevalence, which is consistent with the average lifetime prevalence

4、suggested by Robins et al. (1984). Using the Beck Depression Inventory, Sullivan and Engin (1986) reported that 26 percent of the tenth- and eleventh-grade students in their sample scored within the moderately depressed

5、range, and 6 percent within the severely depressed range. In a classroom of thirty students, a teacher may anticipate that one or two students will exhibit symptoms of depression.,The “Who” of Childhood Depression “哪些人”

6、患兒童抑郁癥,“哪些人”患兒童抑郁癥Korup (1985)發(fā)現(xiàn)，226名6-12歲孩子組成的樣本中有10%的人呈現(xiàn)出抑郁癥狀。Leftkowitz 和Tesiny (1985), 在研究3,020 小學(xué)生時(shí)發(fā)現(xiàn)有5.2%的孩子有抑郁癥。這與Robins 等人(1984)報(bào)告的平均終生發(fā)病率相一致。Sullivan and Engin (1986)等人利用Beck 量表發(fā)現(xiàn)26%10-11年級(jí)的學(xué)生有輕中度抑郁，6%有重度抑郁。在一個(gè)

7、30人的教室里，教師可以預(yù)期有1-2人會(huì)呈現(xiàn)抑郁癥狀。,The "What" of Childhood Depression兒童抑郁癥有什么表現(xiàn),The Diagnostic and Statistical Manual for Mental Disorders (American Psychiatric Association 1979) states that the primary symptom of de

8、pression is a "dysphoric mood" (a loss of interest or pleasure in almost all daily activities). For the diagnosis of depression, a student must exhibit at least four of the following symptoms for a minimum of t

9、wo weeks: change in appetite or weight, sleep disturbance, psychomotor agitation or retardation, loss of interest in usual activities, loss of energy, feelings of worthlessness or excessive guilt, difficulty concentratin

10、g, and thoughts of death or suicide.,The “What” of Childhood Depression兒童抑郁癥有什么表現(xiàn),精神障礙的診斷與統(tǒng)計(jì)手冊(cè)告訴我們，抑郁癥的基本癥狀是“抑郁心境”（dysphoric mood. depression: a state of feeling acutely hopeless, uncomfortable, and unhappy ）（a loss of

11、interest or pleasure in almost all daily activities對(duì)幾乎所有的日?；顒?dòng)都失去了興趣或愉悅）。為了確定一個(gè)抑郁癥的診斷，以下癥狀中的至少4個(gè)必須持續(xù)至少2周：胃口或體重的改變，睡眠的障礙，精神運(yùn)動(dòng)的易激惹或遲鈍，對(duì)日?；顒?dòng)興趣的喪失，精力的喪失，無(wú)價(jià)值感或過(guò)份的負(fù)罪感，注意力難以集中，死亡或自殺的念頭。,The "What" of Childhood Depressi

12、on兒童抑郁癥有什么表現(xiàn),Cantwell (1983a) describes four historical schools of thought concerning depression in children. The first suggested that depression, such as that found in adults, did not occur among children. The second s

13、uggested that depression existed in children, characterized by symptoms not apparent in adults. The third school of thought described "masked depression" or "depressive equivalents" among children. De

14、pression was perceived to assume a different form in children. Children were thought to demonstrate boredom, restlessness, fatigue, difficulties in concentrating, and aggression, rather than the adult behaviors of sleep

15、disturbance, self-reproach, guilt, and loss (Garfinkel and Golumbek 1974). Cantwell indicates, however, that the behaviors that supposedly "masked" childhood depression are found among adults as well. To alert

16、professionals, the child's depression was not "masked.",The "What" of Childhood Depression兒童抑郁癥有什么表現(xiàn),Cantwell (1983a) 描述了歷史上4個(gè)關(guān)于兒童抑郁癥的學(xué)派。1，主張?jiān)诔扇酥锌吹降囊钟舭Y，在兒童中是沒(méi)有的。2，認(rèn)為兒童中存在著抑郁癥，但是其特有的癥狀在成人期表現(xiàn)不明顯。

17、3，描述了兒童中“面具性的抑郁”或“抑郁的等價(jià)物?！痹谶@個(gè)學(xué)派視野中，兒童抑郁癥采取了與成人不同的形式。他們認(rèn)為兒童會(huì)表現(xiàn)出厭倦、躁動(dòng)，疲乏，注意力分散和攻擊性（boredom, restlessness, fatigue, difficulties in concentrating, and aggression），而不是象成人那樣表現(xiàn)出睡眠反常，自我責(zé)備，負(fù)罪感和喪失感(Garfinkel and Golumbek 1974)。然

18、而，Cantwell 指出，那些被認(rèn)為給兒童抑郁帶上面具的行為在成人中也能看到，為了驚醒專業(yè)人員，他認(rèn)為兒童抑郁癥并沒(méi)有被“面具化。”,The "What" of Childhood Depression兒童抑郁癥有什么表現(xiàn),The most recent school of thought suggests that depression in children has a clinical pattern an

19、alogous to that in adults. Though there may be age-specific behaviors among infants, children, and adolescents, the diagnostic criteria for depression remain the same.,The "What" of Childhood Depression兒童抑郁癥有什

20、么表現(xiàn),4， 最晚近的學(xué)派認(rèn)為，兒童抑郁癥具有類似于成人的臨床模式。盡管在幼兒，兒童和青少年中會(huì)有一些帶上年齡特征的行為，但是抑郁癥的診斷標(biāo)準(zhǔn)未嘗有變。,The "What" of Childhood Depression兒童抑郁癥有什么表現(xiàn),Childhood depression is usually identified by inter-viewing the parents and the child,

21、and by using behavior rating scales (Cantwell 1983b). There are several considerations for assessing depression among children (Weller, Weller, and Fristad 1984a). The behaviors exhibited by depressed children may be dif

22、ferent from those exhibited by adults and may be related to the develop-mental level of the child. Kovacs and Paulaniskus (1984) found that less mature students exhibited greater disruptions in experiencing pleasure and

23、were more self- deprecating. Older children exhibited disobedience, op-positional behavior, and complaints of aches and pains. Herzog and Rathbun (1982) also reported develop-mental influences on symptoms of children who

24、 are depressed. They suggested that six- to eight-year-olds exhibited prolonged unhappiness, irritability, and somber affect. Older children exhibited sadness, apathy, helplessness, and irritability.,The "What"

25、 of Childhood Depression兒童抑郁癥有什么表現(xiàn),確珍兒童抑郁癥的方法是與父母和孩子面談，并使用某些行為量表(Cantwell 1983b)。在測(cè)評(píng)兒童抑郁癥時(shí)，有幾件事情需要考慮。抑郁兒童展現(xiàn)的行為也許不同于抑郁成人所展現(xiàn)的，這些行為也許與兒童的成長(zhǎng)水平相關(guān)聯(lián)。Kovacs 和 Paulaniskus (1984) 發(fā)現(xiàn)那些不夠成熟的學(xué)生在高興的時(shí)候會(huì)表現(xiàn)出更多的破壞性行為，并且會(huì)有更多的自我貶低。年長(zhǎng)些的孩子則

26、表現(xiàn)出不服從，對(duì)抗，和抱怨疼痛和不舒服。Herzog 和 Rathbun (1982) 報(bào)告了成長(zhǎng)對(duì)于兒童抑郁癥癥狀的影響。他們認(rèn)為，6-8歲的孩子表現(xiàn)出長(zhǎng)時(shí)間的的不愉快，易怒，和憂郁的情感（prolonged unhappiness, irritability, and somber affect）。更大些的孩子表現(xiàn)出悲傷，冷漠，無(wú)奈和易怒（sadness, apathy, helplessness, and irritability

27、.）。,The "What" of Childhood Depression兒童抑郁癥有什么表現(xiàn),Weller and associates (1984a) suggest that the range of cognitive and language skills among children of various ages affects their interpretations of questions

28、and responses during assessment. Weller and associates (1984a) and Carlson and Cantwell (1980) suggest that some depressed children demonstrate conduct or behavioral disorders. Depression is identified only after thoroug

29、h assessment. Describing depression in children is further complicated by the influences of different situations on behavior. Meyer and Hokanson (1985) found considerable situational specificity in self-reports of the be

30、havior of depressed persons. When stressed by intimates, depressed persons were most likely to exhibit sadness. When similar stresses are imposed by strangers, social withdrawal was the most frequent response. In school,

31、 behaviors may be influenced by the quality of the relationships with teachers and classmates.,The "What" of Childhood Depression兒童抑郁癥有什么表現(xiàn),Weller 和他的同事(1984a)認(rèn)為不同年齡兒童的認(rèn)知和語(yǔ)言技能影響他們對(duì)問(wèn)題的解釋和他們?cè)跍y(cè)評(píng)期間的反應(yīng)。Weller 及其同事(

32、1984a) 以及Carlson 和 Cantwell (1980)指出，某些抑郁的兒童表現(xiàn)出舉止或行為的障礙。只有通過(guò)徹底的測(cè)評(píng)，才能確診抑郁癥。由于不同場(chǎng)面對(duì)行為的影響，對(duì)抑郁的描述就更為復(fù)雜了。Meyer 和 Hokanson (1985) 發(fā)現(xiàn)明顯的場(chǎng)面特殊性對(duì)于抑郁當(dāng)事人的自我報(bào)告的影響。當(dāng)面對(duì)親密者的關(guān)切時(shí)，抑郁癥當(dāng)事人最有可能展現(xiàn)悲傷。而面對(duì)陌生人的類似關(guān)切，他們最頻繁的反應(yīng)是社交的退縮。在學(xué)校中，他們與教師和同學(xué)的關(guān)系的

33、性質(zhì)會(huì)影響他們的行為。,The "What" of Childhood Depression兒童抑郁癥有什么表現(xiàn),Rating scales for child depression, such as the Children's Depression Inventory (Carlson and Cantwell 1982) and the Hopelessness Scale for Children

34、(Kazdin, Rodgers, and Colbus 1986) are attempts to quantify depression and are usually used clinically (Kovacs 1981). Parent and child reports on clinical instruments have not been found to correlate, although clinical i

35、n-struments do distinguish depressed from nondepressed children (Kazdin, French, Unis, and Esveldt-Dawson 1983). Self-report seems to produce the most accurate information, and interviews identify more children with depr

36、ession than do standard evaluation procedures (Carlson and Cantwell 1980). Self-rating questionnaires may eventually be used as screening instruments in that they can be administered to large numbers of subjects, and are

37、 useful in identifying students for more thorough study (Hodgman 1985).,The "What" of Childhood Depression兒童抑郁癥有什么表現(xiàn),測(cè)評(píng)量表如Children‘s Depression Inventory (Carlson and Cantwell 1982) 以及Hopelessness Scale for Ch

38、ildren (Kazdin, Rodgers, and Colbus 1986)。這些量表試圖對(duì)抑郁癥狀進(jìn)行量化，并往往被用于臨床。沒(méi)有發(fā)現(xiàn)父母與孩子運(yùn)用臨床工具給出的報(bào)告之間有相關(guān)性，盡管臨床工具確實(shí)能區(qū)分抑郁與非抑郁(Kazdin, French, Unis, and Esveldt-Dawson 1983)。自我報(bào)告似乎能產(chǎn)生最準(zhǔn)確的信息，而面談比標(biāo)準(zhǔn)的評(píng)估方法能確認(rèn)出更多的抑郁兒童(Carlson and Cantwell 1

39、980)。自我測(cè)評(píng)的問(wèn)卷也許最終會(huì)被當(dāng)作篩選的工具，因?yàn)樗鼈兛梢杂糜诖髷?shù)量的被試，并且對(duì)于確定需要進(jìn)一步研究的對(duì)象而言，也是很有用的。,The "What" of Childhood Depression,Teachers may identify several indicators of depression among their students. Korup (1985) found that depres

40、sed students had significantly lower grades in effort than students who were not depressed, although most were at grade level in reading and mathematics. Depressed students were unable to work or play alone or with other

41、s. Parents reported sleeping problems, physical complaints, and academic difficulties in their children yet were not aware of their children's social withdrawal, tiredness, depressed feelings, and thoughts of suicide

42、. Peck (1981) suggests that students may act out their depression through substance abuse, running away, petty crimes, and aggressive behaviors.,The "What" of Childhood Depression,教師可以在他們的學(xué)生中找到幾種抑郁癥的跡象。Korup (1

43、985) 發(fā)現(xiàn)，抑郁的學(xué)生努力的程度明顯比不抑郁的學(xué)生低，盡管在閱讀和數(shù)學(xué)方面，他們大部分人的成績(jī)?nèi)匀贿_(dá)到平均值。抑郁的學(xué)生難以單獨(dú)或與其他人一起做事或玩樂(lè)。家長(zhǎng)報(bào)告，他們有睡眠問(wèn)題，會(huì)抱怨身體不適，有學(xué)習(xí)上的困難，但是父母往往沒(méi)有覺(jué)察到他們的孩子有社交的退縮，疲倦，抑郁的情感，以及自殺念頭。Peck (1981) 提示我們說(shuō)，抑郁的學(xué)生們也許會(huì)通過(guò)吸毒，離家出走，小型犯罪和攻擊性行為來(lái)發(fā)泄其抑郁情緒。,The "What&q

44、uot; of Childhood Depression,Peers report that their depressed classmates are unpopular, unhappy, and have problems in school achievement (Leftkowitz and Tesiny 1985). Children of both sexes who score in the lower quarti

45、le of reading and intelligence tests are generally at more risk for depression. Symptoms of depression that may be recognized by teachers are summarized in Figure 1.,The "What" of Childhood Depression,伙伴們報(bào)告說(shuō)，抑郁

46、的同學(xué)不受歡迎，不愉快，而且學(xué)校的成就也有問(wèn)題(Leftkowitz and Tesiny 1985)。不管男孩還是女孩，凡是閱讀和智商測(cè)試成績(jī)?cè)谙虏康?/4者，一般來(lái)說(shuō)都具有更高的抑郁的風(fēng)險(xiǎn)。表1總結(jié)了可以被教師察覺(jué)到的抑郁癥狀。,The "What" of Childhood Depression,表1.教師可以觀察到的童年抑郁的癥狀學(xué)業(yè)的征侯

47、情感的征侯學(xué)校表現(xiàn)下降 低自尊失去了參加活動(dòng)的興趣 易激惹努力程度降低，成績(jī)?nèi)詫倨骄?表達(dá)無(wú)價(jià)值或負(fù)罪感成績(jī)問(wèn)題 不受歡迎，疏遠(yuǎn)朋友 悲傷，不快樂(lè)

48、 總以為自己有病 社交活動(dòng)減少,The "What" of Childhood Depression,表1.教師可以觀察到的童年抑郁的癥狀 社交/行為征侯 軀體的征

49、侯多動(dòng) 疲倦難以單獨(dú)做事或玩樂(lè) 年幼學(xué)生尿床或大便失禁年幼的學(xué)生會(huì)有過(guò)度活動(dòng) 精神運(yùn)動(dòng)的燥動(dòng)或遲緩無(wú)精打采 睡眠問(wèn)題攻擊，撒謊，偷竊 年長(zhǎng)學(xué)生的躁動(dòng) 破壞性行為

50、 體重減輕或增加身體不適的抱怨 胃口改變年長(zhǎng)學(xué)生的躁動(dòng) 精力喪失更年幼的學(xué)生的恐怖和/或分離,The "What" of Childhood Depression,表1.教師可以觀察到的童年抑郁的癥狀 認(rèn)知的征侯自殺念頭的表達(dá)無(wú)法集中注意力,The "Why&qu

51、ot; of Childhood Depression 兒童抑郁癥的“為什么”,Current knowledge of the sources of childhood depression is inconclusive (Epstein and Cullinan 1986). Weller, Weller, and Fristad (1984b) suggest several interpretations of childh

52、ood depression. The psychoanalytic model interprets depression as the reaction to the loss of a loved one. The sociological model interprets depression as the result of a social structure that deprives the individual of

53、desirable social roles. In addition, there may be genetic and biochemical explanations of depression.,The "Why" of Childhood Depression 兒童抑郁癥的“為什么”,當(dāng)前關(guān)于童年抑郁的根源的知識(shí)仍然不是結(jié)論性的(Epstein and Cullinan 1986)。Weller, Wel

54、ler, 和 Fristad (1984b) 提示了關(guān)于童年抑郁的幾種解釋。精神分析模式將抑郁解釋為由于親愛者的喪失而產(chǎn)生的反應(yīng)。社會(huì)學(xué)模式將抑郁解釋為社會(huì)結(jié)構(gòu)剝奪了個(gè)人所向往的社會(huì)角色的結(jié)果。此外，也許還有抑郁癥的遺傳學(xué)和生物化學(xué)方面的解釋。,The "Why" of Childhood Depression 兒童抑郁癥的“為什么”,Four of the models that Weller, Weller,

55、and Fristad (1984b) suggest seem more applicable among teachers. The behavior reinforcement model suggests that depressive behaviors are elicited by inadequate or insufficient positive reinforcement. Petti (1983) suggest

56、s that appropriate behaviors decrease through a lack of reinforcement. Powerlessness is produced as a response to the lack of reinforcement and the failure to elicit appropriate behaviors. Depressive behaviors are develo

57、ped, reinforced, and maintained by the limited reinforcement in the environment.,The "Why" of Childhood Depression 兒童抑郁癥的“為什么”,Weller, Weller, 和 Fristad (1984b) 所提示的4種模式更適用于教師。行為強(qiáng)化模式提示說(shuō)，抑郁行為是不適當(dāng)或不充分的正強(qiáng)化所引起的。Pe

58、tti (1983) 提示說(shuō)，由于缺乏強(qiáng)化，適當(dāng)?shù)男袨榫蜁?huì)減少。正強(qiáng)化缺乏所引起的反應(yīng)是勢(shì)孤力單的感覺(jué)，而且會(huì)疏于給出適當(dāng)?shù)男袨?。由于環(huán)境中只有很少的正強(qiáng)化，抑郁的行為就產(chǎn)生出來(lái)，被強(qiáng)化并被維持下去。,The "Why" of Childhood Depression 兒童抑郁癥的“為什么”,A second interpretation applicable in educational settings is

59、that of learned helplessness. The depressed student perceives behavior as independent of reinforcement, leading to a sense of hopelessness. The student develops a cognitive style of attribution that is outside of the sel

60、f (Petti 1983).,The "Why" of Childhood Depression 兒童抑郁癥的“為什么”,第二種適用于教育情境的解釋是習(xí)得的無(wú)能為力。抑郁的學(xué)生感到依靠他的行為是沒(méi)有辦法得到強(qiáng)化的，這就引起了毫無(wú)希望的感覺(jué)。這樣的學(xué)生就產(chǎn)生出一種歸因的認(rèn)知風(fēng)格，認(rèn)為一切事情都不是他所能控制的(Petti 1983)。,The "Why" of Childhood Depress

61、ion 兒童抑郁癥的“為什么”,The third model applicable for teachers is that of cognitive distortion, in which negative conceptualizations of one's view of self, world, and the future are the source of the depression. Depressed

62、children demonstrate a negative cognitive set or hopelessness (Petti 1983). Haley, Fine, Marriage, Moretti, and Freeman (1985) found that depressed and distorted cognitions significantly correlate with psychiatric and se

63、lf-reports of depression.,The "Why" of Childhood Depression,第三種適用于教師的模式是認(rèn)知的歪曲。該模式認(rèn)為，一個(gè)人對(duì)自己，對(duì)世界，以及對(duì)未來(lái)的消極的觀點(diǎn)才是抑郁的源泉。抑郁的兒童展現(xiàn)出一套消極的認(rèn)知或前途無(wú)望的感覺(jué)(Petti 1983)。Haley, Fine, Marriage, Moretti, 和 Freeman (1985) 發(fā)現(xiàn)，抑郁的和歪曲的認(rèn)

64、知與抑郁癥的精神病學(xué)的或自我的報(bào)告之間有顯著的相關(guān)性。,The "Why" of Childhood Depression,A fourth model of depression that is applicable to schools and teachers involves life stress. In this model, stress and environmental changes that r

65、equire readjustment are the cause of depression. Nezu and Ronan (1985), in their analysis of 205 undergraduate students, concluded that negative life events can increase coping problems. The degree to which an individual

66、 actively copes with these problems is a function of coping ability. Effectively resolving problems decreases the likelihood of experiencing depression.,The "Why" of Childhood Depression,適用于學(xué)校和教師的第四種抑郁癥模式涉及到生活壓

67、力。根據(jù)這個(gè)模式，需要重新適應(yīng)的壓力和環(huán)境的改變是抑郁癥的原因。Nezu 和 Ronan (1985), 根據(jù)他們對(duì)于205 名大學(xué)生的分析得出結(jié)論說(shuō)，消極的生活事件可以引起應(yīng)對(duì)的困難。個(gè)體主動(dòng)應(yīng)對(duì)這些困難的程度就是他們的應(yīng)對(duì)能力的功能。有效解決問(wèn)題的能力減少了抑郁的可能性。,What Is a Teacher to Do? 教師可以做些什么？,Cantwell (1983c) maintains that several facto

68、rs must be considered in planning treatment. The teacher, although unable to diagnose and plan the treatment of childhood depression, is invaluable in screening students for further evaluation and cooperating with treatm

69、ent. Here are some specific activities in which teachers may participate. 1. Assist in the identification of students at risk for depression. Students exhibiting the symptoms described should be referred to the school g

70、uidance counselor or social worker. Teachers may be able to assist in initial contacts with parents with whom they have good rapport. Working with children who are depressed is based on an analysis of the strengths and c