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March 06, 2011

「発達障害の二次障害への理解と支援」の講演

 椙山女学園大学で 国立国際医療研究センター国府大病院の齋藤万比古氏の講演を聴いた。
 
何カ所か印象に残った。

①二次性障害をもたない発達障害はきわめて早期に解決できた場合。
 4歳を過ぎて受診したら、ほとんどは二次性が問題になっている。
 人は傷つきながら育ってゆく。傷つきの反復によって生ずる「構え・防衛」が二次障害として表出する。
 誰もが傷つき、誰もが二次性(竹田注:後天的な人格形成と同じ意味だと思う)をもつ。
 能力は傷つくことの代償として生まれることもある(竹田注:マイナス面をカバーするために特定の能力が磨かれる)
 二次障害は必然的に形成した機能であって、なくすことは難しい。
 二次障害・二次性併存障害を抱えて来院した人たちのコアの部分に何があるのかを見いださないといけない
 (竹田注:コアの部分にADHDやPDDのような発達障害があるかどうかを見いださないといけない)

②「ADHDの反社会性の進行・内在化障害の進行」
  ADHDの多くの子は反抗挑戦性障害→行為障害→反社会性パーソナリテイ障害へ、
  あるいは
  受動攻撃的反抗→不安障害・気分障害→パーソナリテイ障害(境界性・回避性・依存性・受動攻撃性)
 とつながっていく事例が多い(齋藤氏は「転げ落ちる」という表現をした)
  ADHD+分離不安、ADHD+社会不安障害が人格障害につながる。
 そのような事態を回避するには家庭・学校・社会で適切な対処をしていくしかない。
  「自尊感情を支えていかないといけない。
  「ADHDの子を叱って放置してはいけない」

③自信の損失を回避することが、反社会性や内在化障害の進行を食い止める大切なポイントになる。
 反抗している子は
 A:不安も大きい
 B:相手を試している。
 [
 「反抗」することで本当に自分を救ってくれる存在かどうかを試している。
 反抗は「必死な叫び」であり「自信のなさ」であり「不満のあらわれ」である。
 この「反抗という『試し』」を超えると、素行障害につながってしまう。
 (竹田注:要するに「反抗」しているうちは、まだ手の打ちようがあるということだ。
 
④「反抗を減らすスキル」として「ペアレントトレーニング」を挙げられる。
 いかの子どもの反抗に攪乱されないか。
 よいことをしたらほめられる・悪いことをしたらほめられない
 これは教室における行動管理と同じである。

⑤ADHDの子は、人にほめられ認められようとしているのだという認識が大切である。

(「セルフエステイーム」「教えてほめる」「エラーレスラーニング」のキーワードを改めて意識できた)

講演では時間切れで話がなかったが、資料の次の箇所も印象的だった。

⑥支援の目標
 発達障害の治療のゴールは症状が完全によくなることではない。
 治療・支援により不適応状態が好転することを通じて、障害の特性を長所も短所も含めた『自分らしさ』として折り合えるようになることであり
このgood-enoughな情緒状態の優勢な時間が維持されるということであり、それらを通じて『これが本当の自分』という肯定的な自己像を獲得し、職業的対人関係的な適応を果たすことにある。

⑦ちなみに椙山女学園の臨床心理相談室は子どもの発達の相談窓口にもなっている。
 パンフには相談料が初回面接3000円、継続面接2000円と明記されている。
 これなら保護者に紹介しやすいと思う。

⑧ICDー10という障害の分類も、「たしなみ」として熟知しておこうと思った。

ICD-10 とは?
International Statistical Classification of Diseases and Related Health Problems(疾病及び関連保健問題の国際統計分類)は世界保健機関(WHO)が作成した分類であり、ICD (国際疾病分類)と略します。その最新版が、1990年の第43回世界保健総会において採択された ICD-10 です。

 ここでは、このうち第V章(F)「精神及び行動の障害」を示します。
--------------------------------------------------------------------------------
症状性を含む器質性精神障害
F1 精神作用物質使用による精神および行動の障害
F2 精神分裂病,分裂病型障害および妄想性障害
F3 気分(感情)障害
F4 神経症性障害,ストレス関連障害および身体表現性障害
F5 生理的障害および身体的要因に関連した行動症候群
F6 成人の人格および行動の障害
F7 精神遅滞
F8 心理的発達の障害
F9 小児期および青年期に通常発症する行動および情緒の障害
F99 特定不能の精神障害

また、F8 心理的発達の障害  の中身は職業柄、知っておきたいと思った。

F80 会話および言語の特異的発達障害
F80.0 特異的会話構音障害
F80.1 表出性言語障害
F80.2 受容性言語障害
F80.3 てんかんにともなう獲得性[後天性]失語[症](ランドウ-クレフナー症候群)
F80.8 他の会話および言語の発達障害
F80.9 会話および言語の発達障害,特定不能のもの

F81 学力[学習能力]の特異的発達障害
F81.0 特異的読字障害
F81.1 特異的綴字[書字]障害
F81.2 特異的算数能力障害[算数能力の特異的障害]
F81.3 学力[学習能力]の混合性障害
F81.8 他の学力[学習能力]の発達障害
F81.9 学力[学習能力]の発達障害,特定不能のもの

F82 運動機能の特異的発達障害
F83 混合性特異的発達障害
F84 広汎性発達障害
F84.0 小児自閉症[自閉症]
F84.1 非定型自閉症
F84.2 レット症候群
F84.3 他の小児期崩壊性障害
F84.4 精神遅滞および常同運動に関連した過動性障害
F84.5 アスペルガー症候群
F84.8 他の広汎性発達障害
F84.9 広汎性発達障害,特定不能のもの

F88 他の心理的発達の障害
F89 特定不能の心理的発達の障害

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