Một số gợi ý chẩn đoán và trị liệu dành cho tre có rối loạn tăng động giảm chú ý gia đoạn đầu tiểu học

MOT SO GOI Y C H A N O O A N V A TR! UEU D A N H C H O TRE CO ROI LOAN T A N G DONG G I A M C H U Y GIAI DOAN DAU TIEU HOC Hoang Thj Nam Phuong Khoa Tdm ly hgc, Dgi hgc Khoa hgc xd hpi vd Nhdn vdn - Dgi hgc Qudc gia Hd Ngi T6M TAT Tdng dpng gidm chu y Id mpt nhifng rdi nhiiu tdm ly difgc chdn dodn nliieu nhdt d hge sinh dp tuoi de'n trudng, ddc biet Id d giai dogn ddn tieu hgc Ire bdt ddu budc vdo mpt mdi irudng hoc tap mdi Viec tim hieu cdc vdn de khd khdn md tre tdng dpng, gidm chii y phdi ddi mat gia nhdp vdo mdi trudng hoc dudng Id mpt viec het sifc quan trgng nhdm phdt hien vd phdng ngifa nhifng that bgt md tie cd the gap phdi Bdi bdo ndy ninh bdy nhimg quan diem ly ludn dugc cho Id nguyen nhdn gdy tdng dgng, gidm chu y vd dita mpt sd kei qud nghien citu ve khd khdn hgc dudng cua tre tdng dpng, gidm chu y giai dogn ddu lieu hgc ddn thdi de xudt mpt sd ggi y chdn dodn vd xdy dimg chuang trinh tri lieu ddnh cho lie tdng dpng, gidm chu y TiJ khoa: Chdn dodn: Tdng dpng gidm chu y; Tri lieu: Rdi nhiiu tdm ly Ngdy nhgn bdi: niimYl; Ngdy duyel ddng bdi: 25I1I2GU Dat vi'n de Theo nhidu thd'ng ke eua cie nghidn cOu tren thd gidi va d Viet Nam, tit ca cac rdi nhidu tim ly gap phai gay anh hudng ddn hoat ddng hgc dudng thi hdi chOng tang ddng, giam chu y la mdt nhOng rdi loan duge chin doin nhidu nhi't d cic phdng khim tim ly Cugc dieu tra vd sOc khde tam thin eia Hidp hdi Tim thin hge Hoa Ky nim 1994 cho thi'y, ty le tang ddng, giam chu y ci tudi hgc dudng tai My Ii 3% - 5% Didu niy cd nghTa la mdt Idp hgc cd 25 - 30 em tht cd thd cd mdt em dugc chin doin vdi tang ddng, giam chu y Viet Nam, mdt sd nghien cOu vd sOc khoe tim than tre em tudi TAP CHI TAM ly HOC, Sd (168), 3-2013 69 den trudng tai Ha Ndi (tidn hinh bdi Benh vien Nhi Trung uong) cho bidt ty le hgc sinh tO den 18 cd cic bidu hien cua tang ddng, giam chii y la 3% (nim 1997) vi 5,25% (nam 2003) Tren thd gidi, lang ddng, giim chu y duge xem nhu mdt nhOng vi'n dd hgc dodng cin phii nhan dugc sy quan tim khdng nhOng cua xa hgi ma edn cia chinh cic nha quin ly va thyc hien chi'nh sich giio due Tuy nhidn, ddi vdi Viet Nam thi ting ddng, giim ehu y vin la mdt vin dd kha mdi Ngay nay, mac du cic thdng tin vd rdi loan tang ddng giam chi y da doge ding tai rit nhidu tren cae phoong tien truydn thdng, song nhin thOc cua cie bic phu huynh cung nhu nhOng nha giio due vd vi'n dd cia tre ed tang ddng, giam chu y doge td't Cac em chua nhin duge su nhin nhan dung din vd vi'n de cua minh cung nhu chua nhan duoc nhOng sy hd trg tich cyc vi dung hudng dd cii thien tinh trang cia bin than Dieu din ddn nguy co ri't cao m i tre cd tang ddng, giim chu y phai dd'i mat gia nhip vio mdi trudng hge dodng Hien nay, cic nghien cOu vd tre ting ddng, giam chu y vi cie phuong thOc trg giup dinh cho trd ting ddng, giim ehu y d nude ta cung chua dugc nhidu; vay, viec di sau nghien cOu vi'n dd niy vi dua cic phuong in can thiep hieu qua la viec lim cyc ky ein thidt nhim gdp phin ning cao chit lugng giio due vi xiy dyng ngudn lyc ngudi giai doan dit nude ta dang thdi ky hdi nhap nhu hidn Cac nguyen nhan va tieu chuin chan doan cua tang dgng, giam chu y / / Nguyen nhdn cua tdng dpng, gidm chu y Cho tdi nay, nhidu ngudn tu lieu khoa hgc vin cho ring, cac tdn thuang vd nao la nguyen nhin chi'nh giy tang ddng, giam ehu y Tuy nhien gin day, mdt nghien cOu da dua so thd'ng ke ring, ton thucmg thin kinh chi chidm 5% tdng sd cie tre dugc ehan doin rdi loan d dang niy Cae nguyen nhin sinh hge cua rdi loan vin li mdt ITnh vuc danh duge nhieu uu tien nghien ciru Cac nghien cOu vd giii phin thin kinh hda than kinh va sinh ly hoe thin kinh da cho thiy ring, ed nhidu su khac biet giOa vung nao trudc cua cic tre ed va khdng ed tang ddng, giam chu y Ngoai cung ed su khic biet vd cic dudi diy than kinh, bach day, thd chai va su lien he giua hai bin ciu Cic ludng vd mat sinh ly nao cho Ihay, nhung di'u hieu bit thodng Ion thdng miu d phan nao trude cQng nho cic di'u hieu khac dudng lien he thin kinh giua hai bin cau nio va he limbic Cd mdt dieu dang Imi y la tic ddng bing thudc thi cac da'u hidn bit thudng cung giam bdt (Carolyn S Schroeder Betty N Gordon, 2002) 70 TAP CHI TAM Ly HOC, Sd (168), 3-2013 Cic bing chOng lim sang nghien cOu vd di truyen cho tha'y, gen eung ddng mdt vai trd kha quan trgng cic nguydn nhin eia ting ddng, giam chu y Nhttng tre cd cha hoae me ed tidn ail chin doin vdi tang ddng, giam chu y cung cd nhidu nguy eo cao mac phai rdi loan niy Faraone, Biederman, Mennin, Gershon vi Tsuang (1996) bio cao ring 84% ty le ngudi trudng cd tidn su chin doan tang ddng, giam chu y cd it nhi't mdt dOa cd ting ddng, giim chu y va 52% sd hg cd tO hai trd len eung cd tang ddng, giam chu y Cdn ddi vdi nhOng ngudi cd anh hoac em cd rdi loan nay, ning hg cOng roi vio didn rdi loan la 11% ddn 32% (Levy, Hay, McStephen, Wood & Waldman, 1997) Nhung sd niy se cao hon ddi vdi nhOng Clip sinh ddi Vdi nhung cap sinh ddi khae trOng, kha nang roi vio khoang 29% ddn 38% cdn ddi vdi nhOng cap sinh ddi eung trOng thi ty le len de'n 51% - 82% (Barkley R.A & Mash E.J., 1996) Gin diy, mdt nghidn eOu mdi dugc cdng bd di giup eho nhOng gia thuydt vd mdi lidn he giOa gen vdi tang ddng, giam chu y eang trd nen ed eo sd hon Ngudi ta tidn hinh didu tra tren nhOng hgc sinh cd tang ddng, giam ehu y la nudi va nhOng gia dinh hgc sinh cd tang ddng, giim chu y li de Ket qui didu tra eho thi'y, chi cd 6% bd me nhiing hge sinh cd tang ddng, giim chu y li nudi eung cd rdi loan tuong ty dd, sd niy d nhOng bd me de la 18% Ngoii ra, mdt sd nha nghidn cOu cdn eho ring, yen td gia dinh vi mdi trudng xa hdi xung quanh la mdt nhOng thinh td ed anh hudng ri't ldn dd'i vdi thyc trang vi benh sO eua tre tang ddng, giam ehu y Tuy nhidn, cho den nay, chung ta vin chua cd mdt bing chOng cu thd nio chOng minh dugc vai trd cia eae ydu td mdi trudng Nhu vay, sd tit ca cic nguyen nhan dugc xem la can nguyen giy tang ddng, giam chO y thi nguyen nhin vd mat di truydn vi thin kinh la hai ydu td duge xem la quan trgng nhit, edn cac ydu td xa hdi va mdi trudng khac ducmg nhu chi ddng vai trd la nhttng ydu td anh hudng khidn cho tinh trang rdi loan trd ndn r5 rang hon 1.2 Chdn dodn vd phdn logi tdng dpng, gidm chd y Hien nay, bing phin loai benh Qudc td ICD phidn bin 10 (ICD-10) va hudng din chin doan vi thd'ng kd benh cia Hdi Tim thin hgc Hoa Ky, chinh ly lin thO IV (DSM- IV) la hai phidn ban cap nhat nhi't vd eie tidu chuan chan doan eae rdi loan tim thin ndi chung vi tang ddng, giim ehu y ndi ridng Dudi day, chung tdi ehi xin trinh biy nhOng tidu chuan chin doin theo DSM- IV-TR Theo DSM-IV-TR (Diagnostic and Statistical Manual of Mentiil Disorders, 4th Edition.Test Revision) thi ting ddng, giam chu y Id sil bieu hien dai dang vd thudng xuyen eua sit thieu tap trung chit y vd.hodc sir hogt TAP CHiTAM Ly HOC, Sd (168), 3-2013 dpnglxung dpng qud mdc hinh thitdng so vdi nhiing tre khdc cdng tudi phdt trien (American Psychiatric Association, 2000, tr 85) Vdi dinh nghTa dd, mdt dOa tre dugc chin doin cd rd'i loan ting dgng giim ehu y neu nhu tre: Mdc phdi (I) hoiie (2): (1) Cd sau hoae hon cac tridu chOng giam tip trung sau diy keo dii it nhi't thing d mOc dd kdm thieh nghi vi miu thuin vdi mOc phit tridn Gidm tap trung: a Thudng khd tip trung cao vio cic ehi tidt hoic thudng mic ldi ciu thi lim bai tip d trudng, d ndi lam vide hay cic hoat ddng khac b Thudng khd tri sy tip trung vao nhidm vu hay cac boat ddng khae c Thudng cd ve khdng chim chi vio nhttng didu ngutri ddi thoai dang ndi d Thucmg khdng theo doi cae hudng din va khdng lam he't bai tip trudng, cic vide vat hoic cic nhiem vu khic (khdng phai chdng ddi hay khdng hieu Idi hudng din) e Thudng khd td chOc cic nhiem vu va boat ddng f Thuong nd trinh, khdng thieh hoic midn cuong tham gia vio cic boat ddng ddi hdi phai ed su tri va nd lyc vd mat tri tue g Thudng quen nhttng vat dung quan trgng phuc vu viec hgc tap (bai tip vd nha, but, sich ) h Thudng dd bj nhang bdi cic kich thi'ch ben ngoai i Thudng dang tri cic boat ddng hang ngiy (2) Cd siu hoic nhidu hon cic trieu chung qua hieu dgng - xung dgng sau diy keo dai it nhi't thing d mOc kdm thieh nghi vi miu thuin vdi su phat tridn cia tre: Qud hieu dpng a Thudng eya quiy tay, chin hoac ca ngudi ngdi b Thudng rdi khdi ghd lap hgc hoac nhung trudng hgp cin ngdi d chd ed dinh ^ Thudng chay hoic leo treo qui mOc nhttng tinh hudng khdng phil hgp ^2 TAP CHI TAM Ly HOC, Sd (168), - 2013 tTnh d Thudng khd khan chai hoic tham gia eie trd choi ddi hdi su vdn •' c Thudng "ludn tay, ludn chan" hoac thudng hoat ddng nhu thd duoc gan ddng co f Thudng ndi qui nhidu Hdp tdp a Thudng dua ciu tra ldi trudc ngudi hdi diit cau hdi xong b Thudng khd chd dgi den luot minh c Thudng eit ngang hoac ndi leo ngudi khae (chen vao cudc trd ehuydn hoac trd choi) A Mdt vai trieu ehOng qui hidu ddng - xung dgng hoac giam tap trung giy ndn su kem thi'ch nghi d ea nhin phai xuit hidn trude tudi len B Sy suy ydu gay bdi eie trieu chOng phii bidu hien d it nhi't hai mdi trudng khic trd len (nhu d trudng hoic noi lam vide hay d nha) C Phai cd bang chimg lam sing rd ring vd sy suy ydu ding kd cic chOc ning xa hdi, hge tap va nghd nghiep D Nhung trieu chOng khdng xuat hien rieng biet cac rdi loan phit tridn lan tda, tim than phin liet hoic loan thin kinh vi khdng thd xep vio mdt dang rd'i loan tim than nio (rd'i loan sic, rd'i loan lo in, rd'i loan phin ly) Tuy theo cie di'u hieu bieu hien cia tre va cic nhdm van dd ma tre thudng xuyen gap phai, DSM-IV cung dua nhirng tieu chi phan loai tang ddng, giam chu y thinh cic the rdi loan cu thd khac nhau, bao gdm: tang ddng giam chu y thd ke't hgp (tang ddng, giam ehu y-C); ting ddng giam chu y thd giam ehu y chiem uu the (tang ddng, giim chu y-I) vi tang ddng giam ehu y thd tang ddng - xung dgng Hien nay, cie tidu chuin chin doin cia DSM-IV vin duge sO dung nhu kim chi nam cho vide chin doin tang ddng, giam chO y Viec xae dinh mdt tre cd mic phai tang ddng, giam ehi y hay khdng phu thudc vao viec nd thda man bao nhieu tidu chi danh gia cua bang phan loai Vide sO dung cic tidu chuin chan doin tren khdng dua lai duge eie ke't qua ehinh xic vd tinh trang cia tre vi cic chi bao kha chung chung, tinh eu thd ehua cao va ddi cdn giy khd ddt vdi nhOng ngodi khdng lam chuyen mdn danh gia tinh trang cua tre (cha me, giio vien) Trong mdt nghidn cOu gan day, vdi ten ggi "Khd khin hgc dudng eia tre ed rdi loan ting ddng giam ehu y giai doan dau tidu hge d TAP CHiTAM LynOC, Sd3 (168), - 2013 73 phd Hue'", chung tdi da thidt kd mdt bang kidm dung dd lam cdng cu chin doan vi phan loai tang ddng, giim chu y vdi ddi tugng thyc hien bang kidm chi'nh li bd me trd - nhung ngudi gin gui tre nhit Thang dugc thidt ke dya tren cic tidu ehuin chin doin cia DSM-IV vi duge eu thd hda bing nhttng bidu hien cu thd Bang gdm cd 27 item duirc xiy dyng theo ba di'u hidu didn hinh cua rd'i loan tang ddng giam chu y: giam chu y, tang ddng va xung ddng Trong cd 10 can diu ndu len eie di'u hidu eua su giam chu y, ciu tie'p theo md ti eac bidu hien tang ddng va bidu hidn edn lai thd hidn tinh xung ddng cua hgc sinh ed tang ddng, giam ehu y Tit ca cac item ddu duge dinh gii theo mOc thudng xuydn tO den 5, dd la khdng bao gid (hoac khdng ed, khdng dung) va li ri't thudng xuydn Ndi dung Bdng kiem chin doin va phin loai tang ddng, giam chu y eua tre (bin danh cho cha me tre) nhu sau: Ldi hudng ddn: Trong vdng ii nhdt thdng qua, xin anhlchi eho biet cda anhlchi cd nhiing bieu Men ndo Irong sd nhiing bieu hien sau ddy? (Khoanh trdn vdo mite dp tuang itng) I = khdng diing; = it khi; = thinh thodng; = thudng xuyen; = rdt thudng xuyen MOc dd STT Cae bieu hien Tre kho tap trung c h i y hoac rit bat can hgc tap cung nhu nhimg cdng viec thucmg Tie khd khan phai tri su chu y cua minh vao mdt cdng viec nao day Luc trd chuyen, tre cd ve khdng ling nghe ldi ngudi ddi thoai Khi (anh) chi dan dd tre didu gi, tre td rit hidu va ghi nhd nhung sau dd thi lai khdng hd thue hidn theo (khdng phiii khdng hidu ldi dan hay cd y chdng ddi) 5 Khi (anh) ehi giao cho tie mgt vide gi Ire phai loay hoay rat lau mdi cd thd bit dau cdng vide Tre thudng xuydn danh mil dd dung cua minh Tie cd ve khdng Ihich hoac nd tranh nhflng bai tap ddi hoi phai suy luan khdng phai vi khdng bidt lam ma vi ludi suy nghT Tie dd bi nhang bdi nhflng am lhanh va lieng ddng bdn ngoai 74 TAP CHI'TAM l y HOC, Sd (168), - 2013 Tre thudng td lo dang hgc tap cling nhu cac boat ddng hang 10 Khi ndi chuydn, tre thudng xuydn chuydn tO mdt chu dd sang mdt chu dd khac 11 Tre khd ngdi ydn hon so vdi cac ban cung tudi 12 Tre thich chay nhay va leo treo d ba't cO noi dau 13 Tre hoat ddng ludn tay ludn chan nhu duoc gin ddng co 14 Ngay ca nhung noi ma tre cin phai im lang hoac ngdi ydn thi tre vin bdn chdn khdng ydn va mudn cua quay 15 Tre thudng nghich dai vi khdng ludng duoc nguy hiem 16 Khi hgc bai d nha tre khdng ngdi yen ma thudng dOng len ngdi xud'ng hoac nghich mdt dd vat gi day thay vi chii tam vao bai 17 Tre thudng hay mic ldi thuc hidn cac cdng vide dugc giao 18 Tre ndi nhieu 19 Khi thuc hien mdt vide gi dd tre vOa thuc hidn vOa ludn mieng hdi (cau hdi cd thd lidn quan den cdng viec hoac khdng) 20 Tre thudng rat khd khan tham gia cac hoat dgng tTnh (choi cd vua, cat dan ) 21 Khi ehoi cac trd choi theo lugt (ca ngya, chay tidp sOc ), tre khdng the kidn tri chd dd'n luot eua minh 22 Tre hay ha'p tip, chua nghe xong cau hoi thi da tra 161 23 Tre chen ngang vao ngudi ldn dang noi chuyen 24 Khi ddi hoi didu gi, tre mud'n ngudi khac phai dap Ong cho tre ngay, nd'u khdng tre se khdc 16c hoac an va 25 Tre td rat hang choi diia vdi cac ban 26 Tre rit dd gian du hoac mat kidm che 27 Tre cau ban va dd buc bdi Vdi he sd eronbaeh anpha ti'nh duge Ii 0,883 (> 0,6), bang kidm dugc xem la cd tin cay cho phep; didm trung binh eua bang kidm la 2,9 vi lech TAP CHITAM Ly HOC, Sd (168), - 2013 75 ehuin luong Ong la 0,37 Khi su dung bang hdi dd tidn hinh sang Igc tren 948 hgc sinh cia trudng tidu hgc tren dia bin phd Hue, kdt qua nghien cihi eho tha'y: ed 44 hgc sinh duge xem li ed cic di'u hieu tang ddng giam chu y, chidm ty le 4,6%, phu hdp vdi cic thdng ke dich td hge tren thd gidi cung nhu d Viet Nam Trong sd 44 tre niy, cd 36 tre roi vao didn rd'i loan thd ke't hcrp, tre thude thd tang ddng - xung ddng chidm ou the vi tre cd bidu hidn cia rdi loan giam chu y trdi mdi didn rdi loan, sd lugng tre nam ed xu hodng vugt trdi hon so vdi nO; dd, ehi ed tre li nO, 38 tre cdn lai la tre nam - sd logng trd nam nhidu gi'p lin so vdi tre nO Bang kidm cia chung tdi chi duge sO dung dd tai va hien lai vin chua dugc ehuin hda Hy vgng ring thdi gian tdi, vdi nhttng nghien cuu siu hon, ching tdi ed thd chuin hda dugc bing kidm cua minh dd nd dugc trd mdt cdng cu nghidn cOu cung nhu thue hanh chin doin va didu trj tang ddng, giim chi y tai Viet Nam Mgt sd khd khan ma tre tang dgng, giam chu y gap phai gia nhap mdi trudng hgc ducmg Tre tang ddng, giam ehu y bit diu co nhttng bidu hien rd'i loan tO rit sdm, tre bit dau chap ehttng bidt di vi thudng ro ban d giai doan miu giio Tuy nhien, phai den tre di Idp 1, tOe li budc vao mgt mdi trudng hgc tap that sy thi nhOng vi'n dd eia tre mdi bieu hien mdt each rd ret va bat diu trd "nan de" khidn cho bd me eung nhu giao vien dau diu Trong mdi trucfng hge tip mdi, tre bit dau trd mdt ei nhin dgc lip, phai hgc cich ty thich nghi vdi nhOng ndi quy, nhung quy dinh cia nha trudng cung nhu ddi vdi ban thin viec hgc tip ban than eae em vdi nhiing rdi loan vdn cd eia minh, chua cd du nhung ky ning dd thue hien nhiing didu dd Chi'nh sy chenh lech ddi hdi cua mdi trucmg mdi vdi vi'n dd tidm in cia tre tang ddng, giim chu y li nguydn nhin gay nen sy kdm thich nghi va ddi din de'n eac thit bai hgc dudng eua cic em Cung khudn khd dd tai nghien cuu vd "Khd khan hge dudng cia trd cd rd'i loan ting ddng giam ehu y giai doan dau tieu hgc d thinh phd Hud'", ching tdi da tidn hanh nghidn cOu mdt sd khd khin m i tre cd rdi loan tang dgng giam chu y gap phai boat ddng hgc tap cua minh (didu tra trdn giio vien vi phu huynh) Tit ci cie vi'n dd niy doge cu thd hda bing cic ciu hdi danh gii mOc vdi thang didm tO ddn va dugc chia lam nhdm: nhdm thO nhit li nhOng khd khin viee thich nghi vdi ngi quy trudng Idp va nhdm thO hai la nhttng khd khin ma trd gap phii ddi vdi cdng viee hgc tip Kdt qua nghien cOu nho sau: ''6 TAP CHI'TAM Ly HOC, Sd (168), - 2013 Trong 13 kho khan dugc liet kd nghien cOu thi nhdm khd khan dd'i vdi viee thieh nghi ndi quy hge dudng cd phan trdi hdn Cu thd li cd ddn 3/13 chi bio nhan duge sd didm trung binh cao va ddu co sy tuang ddng dinh gii giOa ca giio vien va phu huynh, xdp d eie vi tri 1, 2, bao gdm: "Gido vien phdi thudng xuyen nhde nhd thi Ire mdi tap trung vdo bdi" - vdi didm trung binh thu dugc d giio vidn (DTBGv) Id 4,03 va didm trung binh thu dugc d phu huynh (DTBPH) Id 3,68 "Tre khdng the ngdi yen de tiep thu bdi gidng Irong gid hge" vdi DTBGv = 3,94; DTBPH = 3,52 vi "Quen chep bdi tap ve nhd" (DTBGv = 3,61 vd DTBPH = 3,25) Vdi nhdm khd khan thO hai, khd khan thich nghi dd'i vdi ban thin boat ddng hgc tip, cic chi bao mang lai didm sd eao bao gdm: "Tre mat nhieu Ihiri gian ldm bdi" (DTBGv - 3,92: DTBPH = 3,43) "Tre khdng dgt diem sd cao cdc mon hgc ddi hdi sit kien tti (DTBGv = 3,86: DTBPH = 3,23); "Tre thudng lung titng thuc hien cde hogt dpng ddi hdi sir kheo leo" (DTBGv = 3,78, DTBPH = 2,8) Ddi vdi nhung khd khin cdn lai ca hai nhdm, mtte dd dinh gia nim d khoang trung binh, giao dgng tO 2,8 de'n khoang 3,7 Cd mdt didu dac biet d diy li dudng nhu cd mdt sy khdng tuong ddng dinh gii gitta hai nhdm khieh the nghien cOu vdi mdt ben Ii giio vien va ben li phu huynh Cic didm sd danh gia ttt phi'a giio vien thodng eao hon phu huynh tO 0,35 eho ddn khoang 0,7 Sy khic biet danh gii gitta phu huynh vi giio vien d diy khdng cho thiy sy khic biet tinh chit eia eac chi bio ma ehi eh! eho chung ta thay mOc uu tidn vi sy quan tam khae dd'n cic vi'n dd hge dudng cia tie d hai khach thd tren Mgt sd ggi y can thiep va tri lieu 3.1 Nhiing nguyen tdc chung xdy dung chuang trinh Nhu da trinh biy d trdn, eie bidu hien rdi loan cia tre tang dgng, giam ehu y khdng ehi xuit hien d mdt mdi trudng nhi't ma nd tdn tai gin nhu thdng nhit d cic mdi tru&ng khac cho du dd li nha, d trudng hay bit eO mdt bdi canh nao khic Chu trinh chin doin cung nhu tri lieu danh cho tre ting ddng, giam ehu y viy ddi hdi mdt cich tidp can da phuang phip vi da bdi cinh vdi su tham gia khdng nhttng eia nhi trj lieu mi edn ca bd me, nha trudng dd cin phai chu y dac biet den nhung didm manh cung nhu diem ydu cua tre vi ehinh mdi tru&ng gia dinh cia eie em Bdn eanh dd, cin phit luu y ring, mac du vide tri lieu se phii giii quydt rit nhidu cic khia canh khac cia rd'i loan, trgng tim eua nd vin ndn hudng vao vide quan ly cic vi'n de ve hanh vi vi cim xue, giup tre eai thidn nhttng didm ydu kha ning ty kiem che, hudng tdi dieu ehinh nhttng bidu hien khdng phu hgp cho tre a hien tai va tuong lai TAP CHi TAM Ly HOC, Sd (168), 3-2013 77 Mgt ydu td khic cin phai luu y xiy dyng chuang trinh trj lidu eho tre tang ddng, giam chu y la phii hifdng den muc lieu Idu ddi d mdi giai doan phit tridn khic nhau, tie ting ddng, giam chi y lai vi'p phai nhttng vi'n dd mdi ndn chuang trinh can thidp khdng ndn chi tip trung vio cic vi'n dd d thdi didm hien tai mi cdn ein phii lou y Idi vide phong ngOa cic vin de cd thd xiy d nhOng thdi didm toong lai (xem thdm Schroeder Carolyn S., 2002) Mat khic chuang trinh can thiep cung cdn dtft/e xdy dung mat cdch todn dien dd lim nd ed thd dude ip dung nhidu mdi trudng khic Khic vdi nhieu cac rdi nhidu tim ly khae, chu trinh tri lieu tang ddng, giim chu y khdng thd dat dugc ndu chi didn phdng tri lieu vi khoing thdi gian tri lieu ngin ngii giOa tre vi nhi tim ly Dd phai li mdt qua trinh hdt sOc lau dai vi bao trim; cic phuang phap va ky thuit tri lieu khdng chi dugc thyc hien bdi cinh eia phdng khim tim ly mi nhat thidt phai duge thye hien ci nhOng mdi trudng thudng nhat nhu d nhi hay d tru&ng Chinh vi ly dd, viec xay dyng chuang trinh trj lieu eho tre tang ddng, giam chu y phai ldi keo su tham gia cia cic bdn chim sdc sOc khoe (bic sT, nhi tim ly), gia dinh vi nha trodng Tuy nhien, thye td cho thi'y, hiu hdt cie ehuang trinh trj lieu hidn cd tai mdt sd nude tren the gidi vi die biet d Vict Nam dang bd quen eac ydu td hd trg va chim sdc sue khde ban diu bao gdm: trj lieu bing thudc, tham vin/tip huin cho bd me va giao vien cung nhu quen bing di viec xiy dyng chuang trinh phong ngOa va quan ly hanh vi cho irc tai Idp hgc Phai khing djnh ring, khdng cd mdt phuong thudc nio hay mdt ky thuat trj lieu nao cd thd giup eho tre giai quyet het cic bidu hien rdi loan mdt each tOc thdi ma diy thyc sy phii la mdt qui trinh liu dai Mdt viec trj lieu bj dimg lai hay ngit quing, cic vi'n dd cu eua Ire se rat ed kha nang quay trd lai vdi mOc kho khin nhu ban diu Kinh nghiem thyc te eua chOng tdi thue hinh can thiep cho thi'y, viec tri lieu dinh cho tre ting ddng, giam chu y nen duge bit diu cing sdm cing tdt, tdt nhit li vio giai doan tien tidu hge hoae diu giai doan tidu hoe (Idp 1, 2) Bit diu budc vao giai doan vi nien, viec can thiep se khd ban ri't nhidu Sau diy la mgt vii ggi y viec can thiep va tn lieu cho tre ting dgng, giim ehu y danh eho bd me va giao vien Mdt cic ggi y sau duoc ip dung mdt cich triet dc va dung each, khdng nhOng cac vin de hge dudng ma nhidu cic van dd khae cua tie tang ddng, giam chu y cd thd duoc cai thien mgt each tdi da Nhfmg ggi y vd chuang trinh can thiep sau diy dugc xay dyng tren phuong thiic tidp can da chidu va da bdi eanh dd cd ca ggi y tip huin dinh cho bd mc vi giio vidn cung nho each ddi phd vdi nhOng ihay ddi ve mai mdi trudng 3.2 Tap hudn ddi vdi hd me •'S TAP CHI'TAM Ly HOC, Sd (168), - 2013 Vide tip huin cho bd me khudn khd ehuang trinh trj lieu cho tie tang dgng, giam chu y ettng quan trgng khdng kem so vdi vide can thiep tryc tie'p vdi tre Kdt qui cua qua trinh tap huin cho bd me se dim bao cho Ii'nh nhit quan cua qua trinh tri lieu vdi nhi tim ly Thdng thu&ng, vice tip huin ndn duge didn trudc qua trinh can thiep cho tie duoc thyc su bit diu Mdt nha tim ly da ip dung cic nguydn tic hinh vi cho tre thi ddng thdi, bd me tie eung phii tuin thu va ip dung theo Ndi dung tap huan cho cic bac phu huynh bao gdm: (1) Cung ci'p cii nhin so bd vd van dd eua tre tang ddng, giam chu y; (2) Xiy dyng mdt mdi trudng giao due cung ed tai nhi (trong dd bd me phai hidu 10 cae nguyen tic cing cd hinh vi) va (3) Hudng din cho hg each xO ly dd'i vdi nhiing tinh hudng thu&ng gap dd'i vdi tre tang ddng, giam chu y noi cdng cdng (Barkley, 1997b) Ky thuat dugc sO dung nhidu nhit tn lieu cho tre tang ddng, giam chu y la ky thuat quin ly hanh vi Ndi dung chi ydu cia ky thuit niy li tao ndn nhOng cung ed tich cue dd thidt lap cae hanh vi mong mudn Ky thuat niy khdng ndn chi duge truydn dat mdt each chung chung mi bd me (ngu&i cham sdc) ndn dugc giim sit dd thuc hinh vdi chinh cia hg nhOng tinh hudng cu the vi mdi tru&ng cu thd tai d nha rieng Ngoii ra, hg eung nen dugc eung ci'p cic kid'n thOe co ban vd vide nudi day tre cung nhu cie die didm phit trien cia cac em d tttng giai doan khic Nha tim ly cd thd lya chgn nhttng tinh hudng xung dgng cia tre dd cung cac bac phu huynh bit dau qua trinh can thidp bdi vi dd la nhttng tinh hudng ma hieu qua eua ky thuat quin ly hinh vi the hien rd nhat 3.3 Can thiep hgc dudng Nha trudng la mgt hai mdi trudng chi dao cd inh hudng ldn ddn viec hinh thinh hanh vi vi nhan thOc eia tre tang ddng, giam chi y ndn vide cin cd nhung bidn phip can thidp ddi vdi tie mdi tru&ng niy li didu ri't dang phai luu tam Cic ky thuat duge s i dung tai Idp hge bao gdm: thay ddi eie phucmg phip truydn dat bai truydn thdng cua giio vidn (thay ddi cich truyen dat thdng tin/ldi hudng din ddi vdi tre; thay ddi khdi lugng vi hinh thic eae bai tip cho tre ); ddi phd vdi nhttng hanh vi khdng mong mud'n cua tre (xiy dyng he thdng eung cd hanh vi eho tit ca cic giao vien; tap huin eho giao vien cic phuong phip quan ly hanh vi, ting cudng su quan tim eua giao vien ddi vdi cac diu hieu chdng ddi cia tre; thidt lap thdi gian va gdc tach lip Idp hgc; cam ket vd hanh vi ) Mdt sd ky thuit mi giio vien cd the sO dung: (1) Ddn gian hda tdi miic tdi da cie chi din va thdng tin ein truydn dat; (2) Dam bao ring tie hidu hdt ngi dung Idi hudng din trudc bit dau thye hien boat ddng; (3) Ludn dua thdng bio trude mdi lan chuyen sang hoat ddng m6i; (4) Ra thdng bio va thudng xuydn nhic nhd tre vd miu hanh vi mong mud'n; (5) Giup Ire dn bai cu TAP CHiTAM Ly HOC, Sd (168), 3-2013 79 trudc hgc bii mdi; (6) Ldi keo tre vao bii hge bing cich thu&ng xuyen dat eho tre nhttng cau hdi kidm tra hoae tim kiem thdng tin tO bai hgc; (7) Chia nhd cic phin bii tip; (8) Giup hgc sinh ty sua ldi cia minh Cd hai each tidp can khic dd'i vdi ky thuit cung cd: cung cd duong tinh va cing cd im tinh Cung cd duong ti'nh d diy duge hidu la nhttng cung cd Iheo sau hinh vi phu hgp mang tinh khich Id vii dem den sy vui thu ddi vdi tre Cing cd dUdng tinh cd thd thyc hien theo nhidu each khic nhu khen nggi, phin thudng cu thd hay danh eho tie mdt hoat ddng tre thich hoac cd nhttng uu tidn dae bidt Cing ed am ti'nh ngugc lai, dugc hidu li nhttng cung cd duge lya chgn dya trdn viec ddng y cho tre khdng phai lam didu ma cac em cam thi'y khd ehju hoac khdng ydu thich cic em thyc hien doge mdt hanh vi phu hgp (vi du nhu cho phep tre khdi "gdc tich biet" ndu tre chip nhin thyc hien nghiem tic thdi gian phat) Khi sO dung cung cd tich cyc dd ting cucmg eac hanh vi phu hgp cia tre, giio vien phii chu y lim dd tre cam thi'y thich nhin td cing cd va hidu ring cai minh nhin dugc la kdt qua cia hanh vi mi minh vOa thyc hien vi minh se scim nhan dugc nd sau thyc hidn dung didu giio vien yeu ciu Cdn su dung cing cd tieu eye, giao vien cin phai cd sy nhay cam dd lya chgn dung thdi didm va dung tic nhan cung cd Vide lya chgn cing cd tidu cue hay tich eye phu thudc vao dac didm cua tOng dOa tre va tOng tinh hudng khic Mgt nhflng eich su dung nguydn tic cing ed tieh eye la dung mdt van ban ggi li "Bien bin thda thuin giOa giio vidn vi hgc sinh", each dac biet phu hgp vdi nhOng tre ldn Giio vien va hoe sinh cung thao mdt ban thoa thuan, dd ed ghi ro: cic hanh vi hay nhiem vu ma tre phai hoin hoic thyc hien dugc va nhOng phin hdi (sy cing cd) giio vidn se doa Tai lieu tham khao American Psychiatric Association, Diagnostic and statistical manual of mental disorders: DSM-N-TR, Fourth edition, 2000 Barkley R.A & Mash E.J Child Psvpatlioloi>y Guilford Press, NewYork, 1996 Nguydn Thj Van Thanh, "Ddc diem tdm ly ldm sdng ciia hgc sinh lieu hgc cd rdi logn ldng ddng gidm ehu v", Luin in Tidn sT ci'p nha nude, Vien Tim ly hgc, 2010 Levy F., Hay D.A., McStephen M., Wood C & Waldman I., Tdng dpng, gidm chii y: A category or a continuumi Genetic analysis of a large scale twin 80 TAP CHi TAM ly HOC, Sd (168), - 2013 study Journal of the American Academy of Child and Adolescent Psychiatry, 36,tr 737-744, 1997 Schroeder Carolyn S & Gordon Betty N., Assessment & Treatment of Childhood Problems - A Clinician's Guide Guilford Press NewYork 2002 TAP CHi TAM Ly HOC, Sd (168), - ... mud'n ngudi khac phai dap Ong cho tre ngay, nd'u khdng tre se khdc 16c hoac an va 25 Tre td rat hang choi diia vdi cac ban 26 Tre rit dd gian du hoac mat kidm che 27 Tre cau ban va dd buc bdi Vdi... thyc te eua chOng tdi thue hinh can thiep cho thi'y, viec tri lieu dinh cho tre ting ddng, giam chu y nen duge bit diu cing sdm cing tdt, tdt nhit li vio giai doan tien tidu hge hoae diu giai doan... sd 44 tre niy, cd 36 tre roi vao didn rd'i loan thd ke't hcrp, tre thude thd tang ddng - xung ddng chidm ou the vi tre cd bidu hidn cia rdi loan giam chu y trdi mdi didn rdi loan, sd lugng tre