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1 情緒障礙兒童青少年之 DSM-5 診斷理解與輔導介入正向生態系統與友善校園的重構生態系統理論 (ecological systems) Bronfenbrenner 所提出, 重點在於 : 兒童及青少年的成長發展是受生物因素及環境因素交互影響生物因素就是自然生態環境, 環境因素則由兒童的生活環境推廣至外在的世界環境, 這些環境可分為四層 : 1. 微觀系統 : 是指與兒童有切身關係的生活環境包括家庭學校友伴及社區 2. 中介系統 : 是指家庭學校友伴及社區之間的聯繫與相互關係, 如父母與學校相互合作情況, 友伴群體相處的影響等 3. 外在系統 : 是指兒童未直接參與, 但影響兒童及青少年成長的因素, 如父母的工作環境, 學校的教育方向及社區資源的運用等 4. 宏觀系統 : 是指文化政治法律社會階層及世界各地所發生的時事, 因為國際環境的變化必然波及或影響各國的政治經濟生活生態導向的諮詢工作 ( 生態諮商 -Ecological Counseling) 工作重點在於重新概念化幫助案主 / 學生的角色, 主要是能用心去改善調整環境生態的調和, 促使案主能從與環境多重互動中取得所需的資源和有意義的改變目標有下列幾項 : - 促進與改善生態系統, 能創造一個調和的環境 - 讓案主 / 學生與他的環境有更好的適合度 - 關注或致力於學校環境的改善, 例如在領導輔助觀念的倡導團隊合作建構和系統變革上加以努力 - 諮詢的取向主要是個別 - 改善 - 指導的服務方式生態取向心理諮詢的要項 : - 看重脈絡 - 相互的連結與溝通 - 強調合作 - 社會系統支持功能的維持 - 正向意義的創造 - 持續性的塑造 1

2 生態系統導向之諮商與治療 - 台灣經驗 2011 年春 : 四組專業人員合作的輔導體制新紀元輔導行政專任輔導教師秋 : 學生輔導法 School Counselor 學校心理師 School Psychologist 學校社工師 School Social Worker 三個重要的學校生態系統介入任務 : 問題解決成長發展團隊生能直接服務間接服務輔導教師初級預防心理衛生教育 / 方案執行倡議宣導 / 機制建構輔導行政次級介入心理評量 / 諮商 / 個別協助溝通協調 / 諮詢 / 系統協助三級處遇危機處理 / 心理治療 / 個案管理資源連結 / 環境介入 / 重新安置學校心理學校社工圖 2 三級預防輔導實務內涵摘要暨多元專業分工構想圖許育光 (2013) 國小輔導教師實務困境與專業期待分析中華輔導與諮商學報,37 2

3 特教輔導 (Special Education Counseling) 的理念整合與實務教育與治療 - 專業工作的系列光譜治療導向的教育 (Therapeutic Education) 教育導向的治療 (Educational Therapy) 直接服務 : 諮商與個別教育團體與小組工作班級工作生活重構間接服務 : 諮詢團體家長社群生態系統導向之兒童心理行為問題處理模式 -ARCCR ( 許育光,2005) 評估與判斷需求 (Assessment) 資源連結 (Resource) 實際接案與進行兒童諮商 (Counseling) 系統重構教師諮詢與親職諮 (Consultation) 復原力環境的建造 (Resilience) 評估與判斷需求 (Assessment) 轉介者 / 照會者期待? 案主的困境或期待? 案主需要的是什麼?Want Need 支持困境的是什麼? 有哪些資源?Resource 如何開放系統中的資源?Consultation 系統如何穩定的朝向支持和協助?Resilience 診斷與理解生理心理社會多軸向觀點醫學診斷心理診斷 : (1) 認知情緒行為微觀分析 (2) 情境脈絡系統之了解 (3) 介入性 / 教育 / 治療性診斷之形成從診斷衡鑑評估到介入衡鑑是一個歷程 - 動態歷程牽涉 what-why-when-where-who & how 的理解和規劃生態系統觀點的採納 3

4 個別介入 * 生態系統介入兒童與青少年的成長脈絡 (level I) 家庭系統 / 班級系統與社區系統的脈絡 (level II) 專業資源與體系的脈絡 (level III) 學校組織與文化的脈絡 (level IV) 資源連結 (Resource) 學校系統與資源教師 / 認輔老師 / 輔導老師會談家庭系統家長會談社區生態脈絡與系統重要他人支持條件與資源增進基本需求與福利環境重新建構保護與安置醫療資源連結診斷與醫療處理實際接案與進行兒童諮商 (Counseling) 四至六次的諮商談話 / 藝術 / 故事 / 繪本 / 遊戲或活動治療場地與設備倫理與保密議題關係的設定次數的延長與追蹤回到輔導室之後系統重構教師諮詢與親職諮詢 (Consultation) 與第一線的教師進行諮詢輔導老師 / 認輔老師之個案研討家長親職諮詢或教育個案研討與系統改變之目標設定協助輔導人員穩定持續的提高家長親職能力復原力環境的建造 (Resilience) 建立保護因子移除危險因子復原力家庭 & 復原力學校家長教師與社區的持續教育輔導團隊的建構區域輔導資源的連結學校 / 社區 / 醫療等支援網絡的建立 4

5 兒童青少年相關行為與情緒可見之診斷類別神經發展障礙疾患 Neurodevelopmental Disorders 智能障礙 Intellectual disabilities Intellectual disability (intellectual developmental disorder) Global developmental delay Unspecified intellectual disability (Intellectual developmental disorder) Communication disorders Language disorder Difficulties in the acquisition ad use of language across modalities (e.g., spoken, written, sign language, or other) Speech sound disorder Difficulty with speech sound production Childhood-Onset Fluency Disorder Social (pragmatic) communication disorder Impaired social verbal and nonverbal communication) Attention-deficit/hyperactivity disorder (ADHD) Specific learning disorder With impairment in reading In written expression In mathematics Motor disorders Developmental coordination d/o Formerly stereotypic movement d/o Tic disorders:tourette s disorder / Persistent Motor or Vocal tic Disorder Autism spectrum disorder Group formerly autistic disorder, Asperger s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS) into a single ASD Dx Kick out Rett s D/O 5

6 思覺失調症 Schizophrenia Spectrum and Other Psychotic Disorders Schizotypal (personality) d/o Delusional d/o Brief psychotic d/o Schizophreniform d/o Schizophrenia Schizoaffective d/o Substance/medication-induced psychotic d/o Psychotic d/o due to another medical condition 雙極性疾患 Bipolar Disorders Bipolar I d/o Bipolar II d/o Cyclothymic d/o Bipolar D/Os separated from Mood D/Os 憂鬱疾患 Depressive Disorders Disruptive mood dysregulation d/o Major depressive d/o, single and recurrent episodes Persistent depressive d/o (Dysthymia) Premenstrual dysphoric d/o Substance/medication-induced depressive d/o Depressive d/o due to another medical condition Other specified depressive d/o Unspecified depressive d/o 焦慮疾患 Anxiety Disorders Separation anxiety d/o Selective mutism Specific phobia Social anxiety d/o (name in DSM-III) (Social phobia in DSM-IV) Panic d/o Panic attack (Specifier) Agoraphobia Generalized anxiety d/o Substance/Medication-induced anxiety d/o Anxiety d/o due to another medical condition other specified anxiety d/o Unspecified anxiety d/o 6

7 許育光博士情緒障礙兒童青少年 DSM-5 診斷理解與輔導介入 2014 冬 Anxiety Disorders 強迫疾患 Obsessive-Compulsive Disorder Obsessive-compulsive d/o Body dysmorphic d/o Hoarding d/o Trichotillomania (hair-pulling d/o) Excoriation (skin-picking) d/o Substance/medication-induced obsessive-compulsive and related d/o Obsessive-compulsive and related d/o due to another medical condition Other specified obsessive-compulsive and related d/o Unspecified obsessive-compulsive and related d/o 創傷後壓力疾患 Trauma- and Stressor-Related Disorders Reactive attachment d/o Disinhibited social engagement d/o PTSD Acute stress d/o Adjustment d/o Other specified trauma- and stressor-related d/o Unspecified trauma- and stressor-related d/o Reactive attachment d/o, inhibited type or disinhibited type in DSM-IV Reactive attachment d/o Pattern of inhibited, emotionally withdrawn behavior Social & emotional disturbance Has experienced insufficient care Disinhibited social engagement d/o Actively approach unfamiliar adults Has experienced insufficient care Trauma- and Stressor-Related Disorders 解離疾患 Dissociative Disorders Dissociative identity d/o Dissociative amnesia Depersonalization/ Derealization d/o Other specified dissociative d/o Unspecified dissociative d/o 7

8 體化症狀 Somatic Symptom and Related Disorders Somatic symptom d/o Illness anxiety d/o Conversion d/o (Functional neurological symptom d/o) Psychological factors affecting other medical conditions Factitious d/o Malingering was removed Other specified somatic symptom and related d/o Unspecified somatic symptom and related d/o 餵食與飲食疾患 Feeding & Eating Disorders Pica Rumination disorder Avoidant/restrict food intake disorder Anorexia nervosa Bulimia nervosa Binge-Eating Disorder Other specified feeding or eating d/o Unspecified feeding or eating d/o 排泄疾患 Elimination Disorders Graduated from first diagnosed in infancy, childhood, or adolescence Enuresis Encopresis 睡眠 - 醒覺疾患 Sleep-Wake Disorders Formerly primary sleep disorders Insomnia d/o (formerly primary insomnia) Hypersomnolence (formerly primary hypersomnia) Narcolepsy Breathing-related sleep disorders Obstructive sleep apnea hypopnea Central sleep apnea 中樞型 ( 鼻和口腔氣流與胸腹式呼吸運動同時消失 ) Sleep-related hypoventilaytion 換氣不足 Circadian rhythm sleep-wake disorders Parasomnias Non-rapid eye movement sleep arousal disorders, including subtypies Sleepwalking type with sleep-related eating, or with sleep-related sexual behavior 8

9 Sleep terror type Nightmare d/o Rapid eye movement sleep behavior disorders Arousal during sleep associated with vocalization and/or complex motor behavior Restless legs syndrome 性別不悅 Gender Dysphoria Formerly gender identity disorder Gender dysphoria in children (formerly was a specifier) Gender dysphoria in adolescents and adults (formerly was a specifier) Removed specifiers of sexually attracted to fe/males, both, neither Add specifier: with a d/o of sex development posttransition 決裂衝動控制與行為規範障礙疾患 Disruptive, Impulse-Control, and Conduct Disorders Oppositional defiant d/o Intermittent explosive d/o Conduct d/o Antisocial personality d/o Pyromania Kleptomania Other specified disruptive, impulse-control, and conduct d/o Unspecified disruptive, impulse-control, and conduct d/o 物質相關成癮疾患 Substance-Related and Addictive Disorders Substance-Related Disorders Substance use d/o Substance-induced d/o Substance intoxication and withdrawal Substance/medication-induced mental d/o Alcohol-Related Disorders Alcohol use d/o Alcohol intoxication Alcohol withdrawal Other alcohol-induced d/o Unspecified alcohol-related d/o Substance-Related and Addictive Disorders 9

10 許育光博士情緒障礙兒童青少年 DSM-5 診斷理解與輔導介入 Non-Substance-Related Disorders Gambling d/o 性格障礙疾患 Personality Disorders Initially proposed a somewhat dramatic new approach Maintain 6 PD Dx from 10 in DSM-IV Move from a categorical to a trait-based, dimensional classification system 性別偏態行為疾患 Paraphilic Disorders Voyeuristic d/o Exhibitionistic d/o Frotteuristic d/o Sexual masochism d/o Sexual sadism d/o Pedophilic d/o Fetishistic d/o Transvestic d/o Other specified paraphilic d/o Unspecified paraphilic d/o 實例探討 ADHD LD ID 輔導季刊 50-4 目錄( ) 主題論壇新診斷心觀點 DSM-5 的變革與應用精神疾病診斷與統計手冊第五版的關鍵改變及其意涵朱春林從精神科醫療工作者的角度看DSM-5的變革邱南英從 DSM-V 的改變談注意力缺陷過動症未來的鑑定與教學輔導趨勢孟瑛如簡吟文由 DSM-V 的改變談學習障礙未來的鑑定與教學輔導趨勢孟瑛如簡吟文從心智遲緩 MR 到智能障礙 ID 去污名化與跨系統的合作可能翁士恆近期參考專書及相關著作許育光朱春林 2015 個案評估與心理衡鑑實務臺北五南圖書許育光梁啟超 2015 活動治療桌遊與牌卡諮商臺北五南圖書許育光出版中 Dr. Kevin 親子遊戲治療牌卡系列上典出版社許育光出版中兒童青少年心理健康問卷適合國中小心理健康篩檢工作實用冬

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