[摘 要]孤獨(dú)癥譜系障礙(ASD)兒童常共患情緒行為問題,包括焦慮、強(qiáng)迫癥、抑郁癥、失眠等,這些情緒行為問題將加重ASD患兒的核心損害,嚴(yán)重影響其社交和身心健康?,F(xiàn)有研究表明認(rèn)知行為治療(CBT)能通過改變負(fù)面認(rèn)知、抑制不良情緒及減少負(fù)面行為進(jìn)而改善ASD兒童的情緒行為問題。本文針對(duì)國(guó)內(nèi)外開展的CBT在改善ASD的情緒行為方面的治療研究展開綜述,旨在為ASD的綜合治療提供新的方向。
[關(guān)鍵詞]認(rèn)知行為療法;孤獨(dú)癥譜系障礙;情緒行為問題;兒童
Doi:10.3969/j.issn.1673-5293.2024.09.015
[中圖分類號(hào)]R179""" [文獻(xiàn)標(biāo)識(shí)碼]A
[文章編號(hào)]1673-5293(2024)09-0094-05
Research progress on cognitive behavioral therapy for emotional and behavioral
intervention in children with autism spectrum disorder
[Abstract] Children with autism spectrum disorder (ASD) often suffers from comorbid emotional and behavioral problems,including anxiety,obsessive-compulsive disorder,depression,insomnia,etc,which will aggravate the core damage of children with ASD and seriously affect their social and physical and mental health.Existing studies have shown that cognitive behavioral therapy (CBT) can improve emotional and behavioral problems in children with ASD by changing negative cognitions,suppressing negative emotions,and reducing negative behaviors.This article reviewed the therapeutic research on CBT in improving the emotional behavior of ASD at home and abroad,aiming to provide a new direction for the comprehensive treatment of ASD.
[Key words] cognitive behavioral therapy;autism spectrum disorder;emotional and behavioral problems;children
1前言
孤獨(dú)癥譜系障礙(autism spectrum disorder,ASD),是一種伴隨終身的神經(jīng)發(fā)育障礙,以社會(huì)交流障礙、狹隘興趣及重復(fù)刻板行為等為主要特征[1]。在過去的20年間,ASD的患病率一直穩(wěn)步上升,目前美國(guó)患病率超過2.0%[2],國(guó)內(nèi)患病率約為0.7%[3]。而當(dāng)前ASD的治療主要集中在改善患兒社交障礙及重復(fù)行為上,忽視了針對(duì)孤獨(dú)癥兒童情緒行為問題的治療,這些情緒行為問題可能對(duì)他們的學(xué)業(yè)及日?;顒?dòng)產(chǎn)生廣泛而持久的負(fù)面影響,導(dǎo)致對(duì)ASD兒童核心癥狀的干預(yù)效果遠(yuǎn)低于預(yù)期,因此積極干預(yù)ASD患兒的不良情緒行為具有重要意義。
認(rèn)知行為療法(cognitive behavioral therapy,CBT),又稱認(rèn)知行為干預(yù),是一組心理行為治療方法的綜合,旨在改變患者的認(rèn)知模式,從而抑制不良情緒或負(fù)面行為的產(chǎn)生[4]。目前認(rèn)知行為療法可分為五個(gè)階段,包括①評(píng)估及心理教育:找出并評(píng)估關(guān)鍵行為,讓患兒理解自身的行為及接受認(rèn)知行為療法;②認(rèn)知重建:指導(dǎo)患兒從一個(gè)有意識(shí)的角度識(shí)別、評(píng)估自己的想法,從而適應(yīng)或改變不良的思維模式;③行為激活:為患兒安排愉悅感和掌控感較高的活動(dòng)來激活他們的行為,增加患兒積極性的同時(shí)減少回避退縮行為;④暴露:系統(tǒng)地接觸相關(guān)刺激或情況以減少患兒不良的行為及心理活動(dòng),它是治療焦慮、強(qiáng)迫癥等的核心策略;⑤解決問題:發(fā)展對(duì)抗患兒關(guān)鍵行為的技巧,使其學(xué)會(huì)管理不良情緒和行為,并將新的認(rèn)知、情感和行為技能融入日常生活。CBT主要針對(duì)ASD患兒的焦慮、強(qiáng)迫癥、抑郁癥、失眠等情緒行為問題進(jìn)行干預(yù),并可針對(duì)不同的關(guān)鍵癥狀對(duì)干預(yù)策略進(jìn)行一定修改。美國(guó)醫(yī)療保險(xiǎn)和救助中心于2010年將認(rèn)知行為治療列為孤獨(dú)癥譜系障礙的十五種循證實(shí)踐之一,足見其有效性[5]。本文收集并總結(jié)了近年有關(guān)認(rèn)知行為治療改善孤獨(dú)癥兒童情緒行為的最新研究成果,期望能為我國(guó)孤獨(dú)癥兒童的干預(yù)研究提供借鑒和啟示。
2 CBT干預(yù)ASD焦慮情緒
孤獨(dú)癥患兒出現(xiàn)焦慮的概率比正常發(fā)育的同齡人更高,約為40%[6]。經(jīng)研究驗(yàn)證,焦慮水平高的ASD兒童在適應(yīng)學(xué)校環(huán)境、學(xué)習(xí)社交技能、建立友誼、減少自傷行為和解決家庭沖突等方面存在更大困難[7],這將進(jìn)一步加劇ASD的核心癥狀。然而目前只有少數(shù)孤獨(dú)癥患兒接受了足夠的焦慮治療。多項(xiàng)研究、薈萃分析及最近的系統(tǒng)評(píng)價(jià)報(bào)告表明,CBT可有效減少ASD兒童的焦慮[8-10]。且隨著醫(yī)療實(shí)踐的發(fā)展,出現(xiàn)了針對(duì)ASD共患焦慮癥兒童改良的CBT技術(shù)和方案[11]。例如,在Oerbeck等[12]為這一特定人群制定的CBT計(jì)劃中,治療著重強(qiáng)調(diào)認(rèn)知重組和暴露,并加強(qiáng)對(duì)ASD患兒焦慮的心理教育,提高他們對(duì)焦慮有關(guān)的想法、感覺和行為的識(shí)別,培訓(xùn)患兒對(duì)焦慮的認(rèn)知和解決技巧,隨后充分運(yùn)用視覺導(dǎo)向?qū)λ麄冞M(jìn)行大量實(shí)踐干預(yù)。患有焦慮癥的ASD兒童在進(jìn)行為期六個(gè)月的治療后,焦慮癥狀顯著減少。同時(shí),由于對(duì)ASD患兒影響最大的是其家長(zhǎng)及教師等直接接觸者(特別是父母),因此指導(dǎo)他們?nèi)绾斡行cASD兒童進(jìn)行互動(dòng)干預(yù)將對(duì)患兒的情緒和社交行為產(chǎn)生直接影響[13]。一些臨床研究將CBT方案應(yīng)用于ASD兒童的日常生活場(chǎng)景,而非單純醫(yī)療環(huán)境,以便患兒的父母或老師等直接參與他們的治療[14-16]。結(jié)果表明,這些CBT方案可有效減少ASD患兒的焦慮,同時(shí)增強(qiáng)他們的社交能力,且其療效具有長(zhǎng)期效應(yīng)。這種生活干預(yù)模式成本較低且具有較高可行性,可在一定程度上緩解家庭壓力。此外,為使ASD患兒能更方便接受治療,有研究開發(fā)出CBT移動(dòng)應(yīng)用程序[17],這種基于移動(dòng)設(shè)備的改良方案同樣能有效減少孤獨(dú)癥兒童的焦慮,且進(jìn)一步降低了治療成本。隨著對(duì)CBT和ASD的研究深入,有研究表明暴露階段在孤獨(dú)癥青少年焦慮癥的治療中發(fā)揮著至關(guān)重要的作用[18],考慮到這一點(diǎn),未來可能出現(xiàn)針對(duì)ASD共患焦慮癥兒童的更加有效和簡(jiǎn)便的改良認(rèn)知行為療法。
3 CBT干預(yù)ASD強(qiáng)迫癥狀
強(qiáng)迫癥(obsessive compulsive disorder,OCD)是一種常見的情緒行為障礙,患者無法靈活有彈性地管理和調(diào)控自己的情緒,表現(xiàn)出重復(fù)行為或精神行為(強(qiáng)迫行為)以減輕痛苦[19]。OCD是孤獨(dú)癥譜系障礙患者最常見的共患精神疾病之一,相較于正常發(fā)育的個(gè)體,被診斷為ASD的個(gè)體共患OCD的風(fēng)險(xiǎn)高出兩倍[20]。大約17.4%的ASD青少年表現(xiàn)出強(qiáng)迫癥的特征性癥狀[19],顯著降低了他們的生活質(zhì)量。強(qiáng)迫癥對(duì)ASD患者的影響方式與一般人群相似,CBT作為強(qiáng)迫癥的一線治療方法,經(jīng)驗(yàn)證同樣能顯著減輕這一特定人群的強(qiáng)迫癥狀[21]。然而,先前的研究表明,在接受常規(guī)CBT治療后,與僅患有強(qiáng)迫癥患兒相比,患有強(qiáng)迫癥+孤獨(dú)癥的患兒強(qiáng)迫癥癥狀改善較少,這突出了調(diào)整常規(guī)CBT方案的必要性[22]。為更好地適應(yīng)共患孤獨(dú)癥及強(qiáng)迫癥兒童的發(fā)展和認(rèn)知特征,近年來國(guó)外出現(xiàn)一些針對(duì)這一特定人群的改良CBT方案[23-24]。在Jassi等[22]人的研究中,研究小組評(píng)估了新改編的CBT手冊(cè)對(duì)ASD青少年強(qiáng)迫癥的有效性。這種新方案將暴露和反應(yīng)預(yù)防(exposure and response prevention,ERP)作為主要組成部分,以使患兒在治療時(shí)習(xí)得的認(rèn)知功能、情感表達(dá)、社會(huì)交流能力更好融入日常生活,并能在一定程度上預(yù)防復(fù)發(fā)。研究不僅在治療中增加了心理教育階段的療程,并使用迷你層次結(jié)構(gòu)可視化了主要層次結(jié)構(gòu)的每個(gè)步驟。34名患有OCD的ASD青少年接受20次培訓(xùn)后,其強(qiáng)迫癥癥狀、心理社會(huì)功能和家庭健康顯著改善,并在3個(gè)月的隨訪中仍然保持療效。對(duì)于無法直接獲得高度專業(yè)化CBT治療的ASD患兒,基于互聯(lián)網(wǎng)的CBT在未來可能成為一種可行的替代方案[25]。但當(dāng)前國(guó)內(nèi)外關(guān)于治療ASD共患強(qiáng)迫癥兒童的適應(yīng)性CBT方案的研究不多,需要進(jìn)行更多探索以得出更加規(guī)范、有效且便利的CBT方案。
4 CBT干預(yù)ASD抑郁癥狀
抑郁癥是一種常見的心理障礙,以連續(xù)且長(zhǎng)期的心情低落為主要的臨床特征,是ASD兒童常共患的情緒行為問題之一。一項(xiàng)Meta分析研究結(jié)果顯示,約有28.5%的ASD兒童共患抑郁癥[26],然而識(shí)別ASD患兒的共患精神疾病具有挑戰(zhàn)性,因?yàn)檫@些合并癥的癥狀常被ASD的典型癥狀所掩蓋[27],導(dǎo)致ASD患兒持久產(chǎn)生負(fù)面情緒,進(jìn)而出現(xiàn)攻擊行為、情緒亢奮或低落、失眠[28],甚至出現(xiàn)自殺傾向[29]。有研究表明認(rèn)知重建訓(xùn)練可能有益于患有ASD的抑郁青少年[30],CBT通常涉及認(rèn)知重建。一項(xiàng)研究評(píng)估了針對(duì)ASD青少年的抑郁、焦慮和壓力的CBT計(jì)劃,他們對(duì)26名ASD青少年進(jìn)行為期9周的CBT干預(yù),結(jié)果顯示與對(duì)照組相比,治療組ASD患兒的抑郁評(píng)分顯著降低,焦慮無明顯改善[31]。而在另一項(xiàng)評(píng)估CBT對(duì)ASD年輕人干預(yù)作用的研究中,16名ASD患者在經(jīng)歷8周針對(duì)社交焦慮和社會(huì)功能的CBT干預(yù)后,他們的社交焦慮、抑郁癥狀、限制興趣和重復(fù)行為都有明顯改善[32]。此外還有一些研究同樣證明了CBT對(duì)ASD患兒抑郁癥有一定干預(yù)效果[33]。需要注意的是以上研究大多為試點(diǎn)實(shí)驗(yàn),樣本量較小,缺乏代表性,未來需要進(jìn)行更大規(guī)模的隨機(jī)對(duì)照試驗(yàn)來充分證明CBT對(duì)ASD患兒抑郁癥的治療作用。
5 CBT干預(yù)ASD行為及其他
隨著對(duì)ASD及CBT探索加深,研究發(fā)現(xiàn)CBT不僅可改善ASD患兒的情緒障礙,也可改善患兒孤獨(dú)癥相關(guān)的行為問題。在評(píng)估CBT對(duì)ASD兒童的有效性實(shí)驗(yàn)中,受試組患兒的易激惹、多動(dòng)和嗜睡癥狀顯著改善。在后續(xù)的一項(xiàng)研究中,研究團(tuán)隊(duì)對(duì)17名ASD和失眠的兒童及其父母進(jìn)行八個(gè)療程的遠(yuǎn)程CBT治療后,患兒及其父母的睡眠有顯著改善,緩解了患兒的身心負(fù)擔(dān),并明顯減輕了患兒的孤獨(dú)癥癥狀及共患行為問題,如易怒、刻板行為、多動(dòng)和過度嗜睡等[34]。同時(shí),研究發(fā)現(xiàn)CBT可間接改善ASD兒童的相關(guān)癥狀。由于ASD患兒生活的直接接觸者對(duì)他們的影響最大,以往有研究將CBT應(yīng)用于患兒的父母和老師,以減輕他們的疲勞和壓力、改善他們的睡眠[35-36]。黃永[37]研究結(jié)果表明在接受治療后,他們能夠更積極參與孩子的治療,減少了患兒在日常社交互動(dòng)時(shí)產(chǎn)生的焦慮和恐懼情緒,從而提高患兒的治療依從性,進(jìn)而提高ASD兒童的行為能力、人際交往和日常自理技能,緩解他們的孤獨(dú)癥癥狀。此外,出現(xiàn)一些研究將CBT與其他方法結(jié)合來改善ASD患兒特定的癥狀,如將沉浸式虛擬現(xiàn)實(shí)環(huán)境與CBT結(jié)合來緩解ASD患者的特定恐懼癥[38],以及將CBT與推拿療法結(jié)合用于改善合并喂養(yǎng)困難的ASD患兒的營(yíng)養(yǎng)狀況等[39],這些研究都致力于減少ASD兒童的身心壓力,從而使他們更有精力和信心來治療孤獨(dú)癥。未來希望出現(xiàn)更優(yōu)秀的系統(tǒng)化CBT方案,不僅可將治療貫穿ASD患兒生活各方面,且可以針對(duì)患兒的特有癥狀進(jìn)行個(gè)體化調(diào)整,以達(dá)到最佳的治療效果。
6 CBT改善ASD兒童不良情緒行為
目前的研究證實(shí)了CBT在改善ASD兒童不良情緒行為方面的療效,并支持CBT作為ASD標(biāo)準(zhǔn)治療的潛力。此外,我們發(fā)現(xiàn)CBT可改善ASD兒童及成人的情緒調(diào)節(jié)[40]和情緒識(shí)別[41]能力,這些情緒能力與ASD兒童的社交關(guān)系密切。情緒能力的提升將使他們減少焦慮、抑郁等心理問題的產(chǎn)生,改善他們的社交障礙,促使他們更有信心和動(dòng)力回歸正常生活[42]。這可能表明,CBT可通過改善ASD兒童情緒能力來減少其不良情緒行為的產(chǎn)生,進(jìn)而改善他們的社交功能。
然而,現(xiàn)有研究仍存在一些局限性。首先,大多數(shù)研究的樣本量小,不足以代表完整的ASD群體。且ASD癥狀的異質(zhì)性高,CBT可能并非對(duì)所有患兒都有效。其次,在ASD兒童接受CBT干預(yù)時(shí),還有其他因素會(huì)影響研究結(jié)果,例如兒童依從性低和父母態(tài)度消極等。此外,目前進(jìn)行的研究大多來自國(guó)外,國(guó)內(nèi)對(duì)CBT的研究還較為缺乏,我們需要更多的研究支持將CBT應(yīng)用于本土兒童或使CBT適應(yīng)當(dāng)?shù)厣鐣?huì)環(huán)境。在今后的研究中,建議擴(kuò)大樣本量,延長(zhǎng)治療時(shí)間,并進(jìn)行隨訪,以減少其他因素對(duì)結(jié)果的影響,以及對(duì)CBT進(jìn)行適合中國(guó)文化背景的調(diào)整,以提高治療效果。與先前相比,現(xiàn)在大多數(shù)ASD兒童生活質(zhì)量有所改善,并將持續(xù)改善。希望在未來,認(rèn)知行為治療能發(fā)展出更完整、包容性更強(qiáng)的治療方案,為更多ASD患兒提供幫助。通過出臺(tái)相關(guān)公共政策,臨床醫(yī)生與家庭、學(xué)校和社區(qū)合作,提供準(zhǔn)確和現(xiàn)實(shí)的治療支持,改善ASD兒童的學(xué)習(xí)和生活。
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