基于ICF构建注意缺陷多动障碍儿童运动康复方案

doi:10.3969/j.issn.1006-9771.2024.08.005

摘要/Abstract

摘要：

目的基于世界卫生组织(WHO)《国际功能、残疾和健康分类》(ICF)全面分析注意缺陷多动障碍(ADHD)儿童的功能特点，并构建功能导向的个别化运动康复方案。

方法运用《国际疾病分类第十一次修订本》(ICD-11)和ICF，对ADHD儿童的身体结构、身体功能、活动和参与以及相关环境因素进行系统分析。基于ICF“生物-心理-社会”的功能、残疾和健康模式，结合身心交互理论，参照《WHO关于身体活动和久坐行为的指南》(2020)中针对残疾儿童青少年的部分，构建适用于ADHD儿童、以功能为导向的运动康复方案。

结果 ADHD儿童的功能障碍主要体现在精神功能(b1)方面，突出表现为注意力功能(b140)、能量和驱动功能(b130)以及高级认知功能(b164)障碍。在活动和参与方面，主要表现为学习和应用知识(d1)、一般任务和要求(d2)、交流(d3)、人际交往和人际关系(d7)等方面存在局限。此外，用品和技术(e1)、支持和相互联系(e3)、态度(e4)等环境因素影响着疾病的发展。根据指南内容身体活动方式可分为运动技能类活动、体适能类活动和运动项目类活动。建议ADHD儿童每天至少进行60 min中高强度的体适能类活动(如有氧运动)、运动技能类活动(如基本动作练习)，且每周至少进行3次力量/抗阻训练和体育竞赛等高强度运动，同时运动康复方案还应确保提供无障碍环境和适应性辅助技术，以促进ADHD儿童整体功能康复。

结论基于ICF理论架构，结合身心交互理论，参照《WHO关于身体活动和久坐行为的指南》(2020)，构建功能导向的运动康复方案，特别是注意功能以及学习和精神功能。

关键词: 注意缺陷多动障碍, 运动康复, 国际功能、残疾和健康分类

Abstract:

Objective To apply the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) to a comprehensive analysis of the functional characteristics of children with attention deficit hyperactivity disorder (ADHD) and to develop a functionally oriented, individualized exercise rehabilitation protocol.

Methods International Classification of Diseases (ICD-11) and ICF were utilized to systematically analyze the body structure, physical function, activities and participation, and environmental factors of children with ADHD. Based on the ICF's bio-psycho-social model of function, disability and health, combined with the theory of somatic and mental interaction, and referring to the WHO 2020 Guidelines on Physical Activity and Sedentary Behaviour, particularly the sections relevant to disabled adolescents, a function-oriented exercise rehabilitation protocol suitable for children with ADHD was formulated.

Results The dysfunctions of children with ADHD were mainly manifested in the area of mental functions (b1), which was highlighted by attention functions (b140), energy and drive functions (b130) and higher-level cognitive functions (b164). In terms of activities and participation, limitations were primarily observed in learning and applying knowledge (d1), general tasks and demands (d2), communication (d3), and interpersonal interactions and relationships (d7). In addition, environmental factors such as products and technology (e1), support and relationships (e3), and attitudes (e4) affected the progression of the disorder. According to the guidelines, physical activity could be categorised into motor skill-based activities, fitness-based activities and sport-based activities. Children with ADHD were recommended to perform at least 60 minutes of moderate to high intensity fitness activities (e.g., aerobic exercise) and motor skill activities (e.g., basic movement exercises) a day, and at least three times a week of high intensity activities such as strength/resistance training and athletic competitions. The protocol should also ensure an accessible environment and adaptive assistive technology to promote the overall functional rehabilitation of children with ADHD.

Conclusions Based on the ICF theoretical framework, combined with the theory of mind-body interaction, and with reference to the WHO 2020 Guidelines on Physical Activity and Sedentary Behaviour, a functionally oriented exercise rehabilitation protocol was constructed, focusing on the children's attentional function, learning and mental functions.

Key words: attention deficit hyperactivity disorder, exercise rehabilitation, International Classification of Functioning, Disability and Health

中图分类号:

R749.93

戴栖, 武庆昌, 管彦舒, 沈海勤, 鲍捷. 基于ICF构建注意缺陷多动障碍儿童运动康复方案[J]. 《中国康复理论与实践》, 2024, 30(8): 903-913.

DAI Xi, WU Qingchang, GUAN Yanshu, SHEN Haiqin, BAO Jie. Exercise rehabilitation protocol for children with attention deficit hyperactivity disorder using ICF[J]. Chinese Journal of Rehabilitation Theory and Practice, 2024, 30(8): 903-913.

图/表 4

表1

基于ICF的ADHD儿童主要功能障碍分析"

成分	类目及编码	功能类目及编码	内容
身体结构(s)和身体功能(b)	神经系统结构(s1)	脑结构(s110)	大脑白质、灰质体积减少，神经网络连接异常
	精神功能(b1)	特质和个人内在功能(b125)	适应力低下，行为唐突、难以预测
		能量和驱动功能(b130)	冲动控制受损，难以调节和抵制突然的冲动
		睡眠功能(b134)	睡眠效率低下、就寝困难、睡眠潜伏期长、频繁夜醒、早醒
		注意力功能(b140)	注意力难以集中、持续时间短
		心理运动功能(b147)	易兴奋、激动、多动
		情感功能(b152)	情感调节能力差，易出现愤怒、焦虑和悲伤等负面情绪
		高级认知功能(b164)	执行功能障碍，认知灵活性、抑制控制、工作记忆等均下降
	运动相关功能(b7)	随意运动能力(b760)	精细能力障碍、快速轮替不灵活、手眼协调能力低下
活动和参与(d)	学习和应用知识(d1)	集中注意力(d160)	注意力不集中，容易走神，无法抵抗干扰因素
		引导注意(d161)	难以根据任务和情景有意维持注意力
		阅读(d166)	阅读时容易读漏、读错内容，理解能力较差
		写作(d170)	利用文字、符号传达信息的能力低下
		计算(d172)	计算易出错，不擅长利用数学原理进行计算
		解决问题(d175)	难以正确分析问题、建立解决问题的方案并执行
		做出决策(d177)	难以权衡利弊做出正确决策
	一般任务和要求 (d2)	从事单项任务(d210)	难以合理安排日常事务，从事各种任务时步骤混乱、难以执行
		从事多项任务(d220)
		进行日常事务(d230)
		控制应激和其他心理需求(d240)	调节和控制应激能力低下
		管理个人行为(d250)	自制能力低下，易产生多动、冲动行为以及攻击性、破坏性行为
	交流(d3)	交谈(d350)	交谈时习惯性打断他人、说话过多，或表现出不倾听、分心、难以切换角色的特征
	自理(d5)	护理身体各部(d520)	自理能力低下，难以独自护理身体各部位、照顾个人健康，易发生交通意外等安全事故^[9]
		照顾个人健康(d570)
		照顾个人安全(d571)
	人际交往和人际关系(d7)	基本的人际交往(d710)	社交能力低下，难以按照社交原则进行人际交往、建立并维持良好的人际关系
		复杂的人际交往(d720)
		正式人际关系(d740)
		非正式人际关系(d750)
		家庭人际关系(d760)
	主要生活领域(d8)	学校教育(d820)	完成学校各项课程的要求存在困难，课堂效率低下，学业成绩不佳，易留级或辍学
	主要生活领域(d8)	参与游戏(d880)	难以独自或与他人一起玩游戏
	社区、社会和公民生活(d9)	娱乐和休闲(d920)	不喜欢休闲和娱乐活动，生活枯燥
环境因素(e)	用品和技术(e1)	个人消费用的用品和技术(e110)	药物治疗及其副作用
		个人日常生活用的用品和技术(e115)	缺乏针对ADHD儿童特点的日常生活、通信和教育等方面的用品和辅助技术
		通信用的用品和技术(e125)
		教育用的用品和技术(e130)
	自然环境(e2)	光线(e240)	不适宜的光线和声音会干扰ADHD儿童的注意力^[10]
	自然环境(e2)	声音(e250)	不适宜的光线和声音会干扰ADHD儿童的注意力^[10]
	支持和相互联系(e3)	直系亲属家庭(e310)	父母养育压力大，多采用消极、不支持的养育方式
		大家庭(e315)	ADHD儿童经常面临拒绝，大家庭、朋友以及熟人、同伴、同事、邻居和社区成员难以理解ADHD儿童，较少提供关爱
		朋友(e320)
		熟人、同伴、同事、邻居和社区成员(e325)
		处于权威地位的人(e330)	教师难以根据其功能特点设计并实施个别化教学策略
		卫生专业人员(e355)	ADHD诊疗实践中的跨学科协作机制尚未成熟
	态度(e4)	直系亲属成员的个人态度(e410)	家庭氛围不和谐，父母较少参与ADHD儿童的生活
		家庭成员的个人态度(e415)	家庭成员和朋友通常持负面态度，对ADHD儿童缺乏耐心，患儿经常遭受同伴拒绝
		朋友的个人态度(e420)	家庭成员和朋友通常持负面态度，对ADHD儿童缺乏耐心，患儿经常遭受同伴拒绝
		权威人士的个人态度(e430)	师生关系和协作水平较低，易遭受来自教师的负面评价
		卫生专业人员的个人态度(e450)	部分医务人员对ADHD儿童持负面态度
		社会的态度(e460)	社会对ADHD以及患者存在错误的认识，易产生偏见
		社会准则、实践和观念(e465)	社会对ADHD以及患者存在错误的认识，易产生偏见
	服务、体制和政策(e5)	社会保障的服务、体制和政策(e570)	ADHD儿童家庭面临较大经济压力，缺少相关保障和福利政策
		全社会支持的服务、体制和政策(e575)	ADHD儿童家庭面临较大经济压力，缺少相关保障和福利政策
		卫生的服务、系统和政策(e580)	缺乏有关医疗康复和促进ADHD儿童健康生活方式的服务、体制和政策
		教育培训的服务、系统和政策(e585)	缺乏专业的培训机构、教师和政策支持

表1

图1

表2

基于ICF的ADHD儿童运动康复方案"

活动形式	活动内容	活动量	涉及功能		运动康复效果
活动形式	活动内容	活动量	身体功能	活动和参与	运动康复效果
体适能类活动	有氧运动：如慢跑、游泳、骑自行车等	MVPA 每天≥ 60 min	睡眠功能(b134)、注意力(b140)、心理运动功能(b147)、情感功能(b152)、高级认知功能(b164)	集中注意力(d160)、控制应激和其他心理需求(d240)、阅读(d166)、写作(d170)、计算(d172)	提高睡眠功能、注意力和认知功能、改善情绪和行为冲动，间接提高学习能力
	力量/抗阻训练：如引体向上、仰卧起坐、俯卧撑、高抬腿等	VPA每周≥ 3 d	特质和个人内在功能(b125)、情感功能(b152)、高水平认知功能(b164)	从事多项任务(d220)	缓解焦虑、抑郁等负面情绪，提高认知功能
	灵敏性运动：如跳绳、健身操等	MVPA 每天≥ 60 min	注意力功能(b140)、高级认知功能(b164)、随意运动能力(b760)	集中注意力(d160)、引导注意(d161)、解决问题(d175)、做出决策(d177)	改善运动协调能力、执行功能、注意力集中度以及做出决策和解决问题能力
运动技能类活动	粗大/精细活动：如慢跑、快走、抓握等	MPA每天≥ 60 min	注意力功能(b140)、随意运动能力(b760)	集中注意力(d160)、护理身体各部(d520)、照顾个人健康(d570)	改善注意力不集中，提高手眼协调能力和自理功能
运动技能类活动	基本动作练习：如跳跃、攀爬、接球、投掷、单脚平衡等	MPA每天≥ 60 min	注意力功能(b140)、随意运动能力(b760)	集中注意力(d160)、护理身体各部(d520)、照顾个人健康(d570)	培养基本动作技能、改善注意力不集中，提高平衡能力、协调能力和自理能力
运动项目类活动	体育游戏：如丢手绢、开火车、老鹰捉小鸡等	MPA每天≥ 60 min	注意力功能(b140)、心理运动功能(b147)、高级认知功能(b164)	从事多项任务(d220)、管理个人行为(d250)、交谈(d350)、基本的人际交往(d710)、参与游戏(d880)、娱乐和休闲(d920)	提升注意力、认知和心理运动控制能力，以游戏规则约束自我行为，改善人际交往和处理任务能力
	体育竞赛：如篮球、足球等	VPA每周≥ 3 d	特质和个人内在功能(b125)、能量和驱动功能(b130)、高级认知功能(b164)	从事多项任务(d220)、管理个人行为(d250)、交谈(d350)、控制应激和其他心理需求(d240)、复杂的人际交往(d720)、非正式人际关系(d750)	提高认知功能、驱动力和适应能力，学会协作与沟通，培养团体意识，改善人际交往能力
	休闲体育：如瑜伽、太极、普拉提等	MPA每天≥ 60 min	能量和驱动功能(b130)、注意力功能(b140)、心理运动功能(b147)	基本的人际交往(d710)、非正式人际关系(d750)、娱乐和休闲(d920)	提高注意力和冲动控制能力，减少多动，改善人际交往，加强人际关系的维持

表2

图2

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