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发展协调障碍

维基百科，自由的百科全书
Developmental coordination disorder
又称Developmental motor coordination disorder, developmental dyspraxia
类型活动障碍[*]、特殊性发育障碍、疾病
分类和外部资源
医学专科Psychiatry, neurology
ICD-116A04
ICD-9-CM315.4
DiseasesDB31600
MedlinePlus001533
[编辑此条目的维基数据]
维基百科中的医学内容仅供参考，并不能视作专业意见。如需获取医疗帮助或意见，请咨询专业人士。详见医学声明。

发展协调障碍（developmental coordination disorder，DCD）[1][2][3][4][5][6][7]也称为发展性协调障碍[8]、发育性运动协调障碍[9]、动作协调障碍[10]或动作障碍[11][12][13][14]是一种神经发展障碍。其特征是大脑讯息无法准确传递到身体，导致肢体协调受损。动作技能的缺失随着儿童的实际年龄干预日常生活活动[15]。发展协调障碍只在没有其他神经损伤（例如大脑麻痹[16][11]、多发性硬化症或帕金森氏症）之下方可诊断。

根据加拿大CanChild的说法，这种疾病影响5%到6%的学龄儿童[17]。不过这种疾病确实会发展到成年，成为终身的健康状况。

征象和症状

由于无法治愈，发展协调障碍影响各种发育，将会持续到成年[14]。通常发展出各种应对策略，应对策略能够透过职业治疗、物理治疗、语言治疗、心理治疗及心理动作治疗加强。

肢体受损之外，发展协调障碍影响记忆（尤其工作记忆）[18]。患者难以记得指令、限期及管理时间，并且倾向忘记物品以及难以执行需要记得多个步骤的任务（例如煮食）。纵使人们普遍在某程度上也碰到上述难题，上述难题却更大程度上影响患者的生活[19]。很多患者虽然短期记忆差劲，长期记忆却出色[19]。患者受惠于有序环境，因为重复例行程序减低时间管理的难度，患者也能够将步骤置于长期记忆当中。

患者有时难以调整来自身体的感官资讯。因此，这些患者也许容易遭受感官过度负荷和恐慌发作[19]。

有些患者遭遇肢体动作的中度至极端困难。由于正确执行肢体动作消耗大幅能量，导致发展协调障碍患者普遍疲惫。肌肉张力减退及肌肉张力低同样损害一些发展协调障碍患者的平衡力[2]

一般运动控制

全身动作和动作协调问题指主要发展目标（包括步行、跑步、攀爬和跳跃）受影响。遭受的困难因人而异，可能包括以下行为：

  • 节拍不当[20]
  • 平衡力差[20][21]（有时甚至中幅度步行摔倒，常见自己绊倒自己）
  • 难以合并一连串受控动作
  • 难以记得下一个动作
  • 难以意识空间[21][22]或肌肉运动知觉。
  • 难以拾起及握住简单物品如铅笔，因为肌肉张力或肌肉运动知觉差劲
  • 笨拙到碰跌物品令自己受伤及不小心撞到人
  • 左右不分
  • 常见交叉用手、转换惯用手、双撇子
  • 难以咀嚼食物

精细动作控制

精细动作问题导致难以执行多方面的任务，例如使用刀叉、扣钮、绑鞋带、煮食、刷牙、弄头发、剃须[2][23]、化妆、保养、打开瓶罐及包装、锁门及开锁、做家务。

精细动作协调问题也会导致书写困难[2]，或许出自联想或联想动作困难[20][24]。行为可能包括：

  • 学习基本动作[25]
  • 建立想要的书写速度[23]
  • 正确握笔[23]
  • 难以阅读的笔迹，以可能漏字或错误排列文字
  • 排列字位——例如拉丁字母以及数字

发展性言语失用症

发展性言语失用症（DVD）是一种联想障碍性失用症，导致言语障碍。英国支持这个术语，但发展性言语失用症有时被称为构音运用障碍（articulatory dyspraxia），在美国通常称为儿童期言语失用症（childhood apraxia of speech, CAS）[26][27][28]。

主要行为包括：

  • 难以控制言语器官
  • 难以发音
  • 难以发出一连串的声音
    • 单字音节，以及
    • 以单字组成句子
  • 难以控制呼吸、抑制流涎和唱歌时发声（有歌词）。
  • 语言发展缓慢

相关失调及二次后果

发展协调障碍患者也许有以下共病：

不过，发展协调障碍患者不太可能同时具备上述所有条件，其遭受困难的程度因人而异。一个患者的主要弱项可能是另一个患者的强项或天赋。例如有些患者有读写障碍，或计算障碍，其他患者却或许有出色的阅读、拼写或数学能力。ADHD和发展协调障碍的共病率特别高，大约50%（一半发展协调障碍患者有ADHD，一半ADHD患者有发展协调障碍）[43][44][45]。

感官处理障碍

感官处理障碍（SPD）是对于生理刺激的过度敏感或过度不敏感（例如触觉、视觉、听觉及嗅觉）[46]。可能外现为无能力忍受某种质地（例如砂纸）或布料（例如羊毛）、口腔无法忍受口感过于丰富的食物（普遍被认为挑食）、被触碰（触觉过度敏感的个案）、或由于阳光使其不适而需要定期在户外使用太阳眼镜（视觉过度敏感的个案）。厌恶响亮音乐及本身响亮的环境（如舞厅及酒吧）是听觉过敏的典型表现，只有在异常温暖或寒冷环境之下才感到舒适是温度过敏的典型表现。对刺激过于不敏感也许会造成困难，因为个人缺乏足够的感官资讯去理解身体在空间的哪个位置，令其更难以完成任务[47]。对痛楚过于不敏感或许不意识自己受伤。

发展性言语障碍

发展性言语障碍（DLD），前称特殊语言障碍（specific language disorder, SLI）、接受性-表达性混合语言障碍或言语障碍。研究发现拥有正常语言技巧的发展协调障碍学生仍然经历学习障碍。即是说，发展协调障碍学生遭遇的学习障碍取决于其工作记忆能力。任何语言强项不足以完全支持其学习[41]。

发展协调障碍学生的视觉空间记忆遭受最大障碍。患有发展协调障碍的学生相对可能在视觉空间记忆得到差劲的分数，比没有此障碍的同侪高出7倍[48]。视觉空间记忆受损是一种工作记忆受损，导致患有发展协调障碍的学生同时出现学习障碍[49]。

心理和社交后果

心理层面：发展协调障碍儿童也许遭受社交上比同侪较低的自我效能，以及认为自己的能力比同侪低。有些儿童展现更高程度的攻击性及活跃度[50]。

社交层面：儿童也许更容易遭受社会排挤及欺凌，或许令其更孤独[50]。

诊断

评估发展协调障碍通常需要潜在患者的童年发展历史[12]，患者的童年发展历史需要详细说明重要的儿童发展阶段（如爬行和步行）在甚么岁数发生[5][11][29]。

为了诊断儿童是否患上发展协调障碍，美国精神医学学会列出四种包括性的主要诊断准则[29]。

准则如下：

  1. 动作协调大幅降少，智力正常
  2. 动作协调或动作规划的困难干预儿童日常生活
  3. 动作协调困难不是出自其他医疗状况
  4. 即使有共病（如智力障碍或其他发展障碍），动作协调仍有不成比例的影响[12]

能够应用于发展协调障碍的筛查包括：

  • Movement Assessment Battery for Children (Movement-ABC – Movement-ABC 2)[51][52][53][54][55]
  • Peabody Developmental Motor Scales- Second Edition (PDMS-2)[51]
  • Bruininks-Oseretsky Test of Motor Proficiency (BOTMP-BOT-2)[51][56][57][58]
  • Motoriktest für vier- bis sechsjährige Kinder (MOT 4–6)[51][59]
  • Körperkoordinationtest für Kinder (KTK)[51]
  • Test of Gross Motor Development, Second Edition (TGMD-2)[51]
  • Maastrichtse Motoriek Test (MMT)[51]
  • Wechsler Adult Intelligence Scale (WAIS-IV) 
  • Wechsler Individual Achievement Test (WAIT-II) 
  • Test Of Word Reading Efficiency Second Edition (TOWRE-2) 
  • Developmental Coordination Disorder Questionnaire (DCD-Q).[60] 此问卷已译成多种语文，例如法文人士可用加拿大法文版[61]或欧陆法文版[62]。
  • Children's Self-Perceptions of Adequacy in, and Predilection for Physical Activity (CSAPPA)[63]

目前没有单一评估测试[51]。

最低限度的动作评估是介入发展障碍的起点。对比正常儿童的发展速度或许有助寻找患童明显遭受困难的方面。

不过，《英国特殊教育杂志》的研究显示，仍然严重缺乏有关识别及应对各种困难的知识（包括发展协调障碍、阅读障碍、DAMP）[29]。及早留意及评估能够更快介入。如果老师或全科医生只是粗略诊断，很可能会错过有需要的患者。

“如果老师知识有限，就无法识别或帮助学习障碍的儿童。相似地，医生难以侦测及转介学习障碍儿童到适当的地方。”[64]

分类

发展协调障碍在《精神疾病诊断与统计手册第五版》 (DSM-5) 归类为动作障碍，位于神经发育障碍类别[65][66]。

控制

发展协调障碍无法治愈，只能透过治疗控制。物理治疗或职业治疗能够帮助患者。

有些患者利用替代方法帮助自己，例如打字取代写字，或利用日记及日历保持条理[67]。Cochrane在2017年审核对发展协调障碍的任务导向介入，得到不一致的结果，呼吁随机化对照组及进一步研究[68]。

流行病学

发展协调障碍是终生神经系统状况，男性和女性同样普遍。不过目前的诊断准则有利男性，导致超过80%男性在16岁前确诊，相对22%女性。发展协调障碍的实际比例是未知，由于缺乏具体实验室测试而难以侦测。因此，只要诊断出其中一种状况就会排除其他可能的原因或疾病。大约5%-6%儿童及成人受此影响[2][4][5][69]。

历史

Collier首先形容发展协调障碍为“先天性发育不良”。1972年，A. Jean Ayres形容发展协调障碍为感官统合障碍[70][71]。1975年，医学博士Sasson Gubbay称之为“笨拙儿童症”[12][31][72]。发展协调障碍也曾被称为“最低度脑部失能”，后两者已不再使用。

其他名称包括发展性失用症[12]、注意力和运动感知障碍（DAMP）[12][31]、动作障碍[11]、发育性运动障碍[12]、动作学习障碍[12][31]感知动作失能[12][31][71]和感官动作失能[12]。

世界卫生组织目前将发展协调障碍列作“动作功能的具体发展障碍（"Specific Developmental Disorder of Motor Function"）”[11]

流行文化

Ryan Sinclair是BBC科幻电视节目《神秘博士》中博士的人类伴侣，患有这种失调。该角色于2018年首次亮相。[73]

著名案例

公开表明确诊发展协调障碍的人包括《哈利波特》演员丹尼尔拉德克利夫[74]、摄影师大卫贝利[75]、模特卡拉迪瓦伊[76]、歌手弗洛伦斯韦尔奇[77]、英国政治家艾玛勒威尔巴克[78][79]、橄榄球联盟球员Ellis Genge[80]、演员Will Poulter[81]、歌手Mel B[82]、演员Olive Gray[83]、作家Holly Smale[84]、游戏评论家John "TotalBiscuit" Bain[85]和音乐家托亚·威尔考克斯[86]。

参见

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