多重障碍儿童复健相关议题.ppt
多重障礙兒童復健相關議題,天主教台東聖母醫院物理治療師陳志軒,今日主題,多重障礙的定義與類別多重障礙相關的醫療問題視多障兒童兒童視覺發展視多障兒童的教育,多重障礙的定義(美國),美國94-142公法的施行細則:多重障礙意指多種障礙的伴隨出現,(諸如智能不足與盲,智能不足皆肢體障礙)這種障礙的併合所造成的嚴重教育問題,非單為某一個障礙而設的特殊教育方案所能適應,多重障礙的定義(台灣),教育部(民國91)多重障礙係指具兩種以上不具連帶關係且非源於同一原因造成之障礙而影響學習者衛生署(民國91)具兩類或兩類以上障礙者,多重障礙的分類,Kirk&Gallagher,1983:以智能為主的多重障礙 智能不足兼腦性麻痺 智能不足兼聽覺障礙 智能不足兼嚴重行為問題2.以情緒困擾為主的多重障礙 自閉症(行為問題與語言發展遲滯)情緒困擾兼視聽覺障礙3.視聽感官的雙重障礙,多重障礙的分類,教育部(民國81)以智能不足為主的多重障礙以視覺障礙為主的多重障礙以聽覺障礙為主的多重障礙以肢體障礙為主的多重障礙以其他某一顯著障礙為主的多重障礙,出現率,第二次特殊兒童普查(民國82)614歲學齡兒童中有7,315人,佔身心障礙學齡人口的9.68%每人平均合併2.41種障礙項目 合併障礙人次以智能不足最多,肢體障礙其次!,多重障礙常出現的醫療問題-癲癇,腦細胞異常放電所導致突然且紊亂的狀況,連帶造成意識或行為的改變或者出現不自主的動作任何疾病不管直接或間接造成腦部傷害都有發生癲癇的可能復發率高的慢性病影響孩子的專注力及訊息處裡的能力控制癲癇的藥物常有副作用,有些會影響孩子的學習癲癇表現的型態有2030種之多每個孩子表現皆不一樣議會隨時間而改變,發作型態的分類,全身性發作（兩側對稱性發作）失神（absence）肌陣痙攣(myoclonic)強直型肌陣攣(tonic clonic)失張性發作(atonic)局部性發作單純局部動作徵兆之發作simple partial with motor symptoms（意識不受影響）複雜性局部發作complex partial（意識受影響）,處理程序,保持冷靜讓孩子躺在穩固的平面並將頭抬高轉向一邊摘下孩子的眼鏡或項鍊鬆開脖子衣物持續觀察直到孩子醒來若孩子停止呼吸或發作超過 10分鐘請趕快送醫不要束縛孩子不要在孩子口中塞任何東西為完全清醒前不要給予食物或飲料,常見的藥物,帝拔癲（valprorate）:減少興奮性神經傳導副作用：體重增加、掉頭髮、腸胃不適體質反應：胰臟炎、血小板下降、肝衰竭魯米拿（phenobarbital）:副作用：嗜睡、憂鬱、過動、過敏性紅疹癲通（carbamazepine）利福全（clonazepam）,其他注意事項,服藥規律性不迷性偏方避免過度勞累及劇烈運動避免劇烈的刺激均衡飲食避免過份溺愛及正常生活空間洗澡最好淋浴家具擺設避免尖銳家具,為甚麼強調視多障？,孩童的學習過程視覺佔有絕大的比例:視覺 42%觸覺17%聽覺 25%視多障的估計說法不一:4090的重度或極重度障礙幼兒會同時有視覺障礙（Cress,Spellman,DeBriere et al,1985）多重障礙的孩童不要忽視其視覺得評估功能性視覺的評估將會影響到多重障礙孩童復健及教學上的策略,視覺障礙,由先天或後天的原因導致視覺機構之構造或機能發生部分或全部之障礙,以致對外界事務無法或很難做視覺的辨識視覺機構:眼球,視神經,視覺中樞鑑定工具:萬國視力檢查表(C)斯奈倫檢查表(E):較適合特教育,多重障礙常伴隨的視覺障礙類別,全盲:優眼視力未達0.03弱視:優眼視力0.030.3 或視野未達20度皮質盲:能清楚收到影像但是卻無法處理或解釋收到的視 覺訊息,損傷在大腦皮質視覺區或後輸的視覺通路視野缺損:視網膜缺損或皮質盲 斜視近視,視障兒教學的特點,全盲對物件的概念強調真實物品的經驗而非玩具或模型觸覺的區辨特別的語文概念及口語描述弱視物品或圖片的距離顏色對比的背景減少視覺的干擾視野有缺損的孩童將物品放置在最清楚的視野注意孩童視覺使用的視野評估剩餘視覺,視障兒教學的特點,皮質盲避免過量提供孩子多元感官的刺激有助於專注和處理視覺的訊息鼓勵孩童注視及觸摸物品而非只有觸摸或只是注意物品物品採分散是擺放以減少孩子的壅塞感實際物品來提昇注意力及語言的發展善用色彩:尤其是黃色及紅色有助於區辨物品或突顯所呈現的材料 因為當神經受損時,相較於對外形與物件的知覺,對顏色的知覺較不易受到傷害,Sensory experience from the external world can influence how the brain wires itself up after birth.Visual experience is crucial for a childs vision to develop normally-a use it or lose it situation.Treatment of common childhood eye diseases should begin much earlier than standard practice.,視覺的發展,視覺的發展,視覺動作的發展視知覺的發展:視覺注視 物體辨識兩者相輔相成互相影響,視知覺的發展,了解嬰兒能力的關鍵在於認明嬰兒反映能力轉頭被認為是能開啟未知嬰兒知覺世界的鑰匙研究者常使用:偏好注視法或習慣化法來研究嬰兒的世界了解嬰兒視知覺的發展可幫助多重障礙兒童的教育及教材設計,注視模式,引起注意與維持注意的區分引起注意:定向反射(與生俱來)環境掃描(先注視輪廓再注視內部)(水平而後垂直)維持注意:刺激的複雜度(感覺飽和度),視覺辨識,視覺敏銳度:區別視覺刺激,看清楚物體之間 相似及相異的能力 物體的移動色視覺,視覺動作,反射凝視追視目光轉移調焦能力,Birth to 6 weeks of age:,Stares at surrounding when awake Momentarily holds gaze on bright light or bright object Blinks at camera flash Eyes and head move together One eye may seem turned in at times,8 weeks to 24 weeks:,Eyes begin to move more widely with less head movement Eyes begin to follow moving objects or people(8-12 weeks)Watches parents face when being talked to(10-12 weeks)Begins to watch own hands(12-16 weeks)Eyes move in active inspection of surroundings(18-20 weeks)While sitting,looks at hands,food,bottle(18-24 weeks)Now looking for,and watching more distant objects(20-28 weeks),30 weeks to 48 weeks:,May turn eyes inward while inspecting hands or toy(28-32 weeks)Eyes more mobile and move with little head movement(30-36 weeks)Watches activities around him for longer periods of time(30-36 weeks)Looks for toys he drops(32-38 weeks)Visually inspects toys he can hold(38-40 weeks)Creeps after favorite toy when seen(40-44 weeks)Sweeps eyes around room to see whats happening(44-48 weeks)Visually responds to smiles and voice of others(40-48 weeks)More and more visual inspection of objects and persons(46-52 weeks),12 months to 18 months:,Now using both hands and visually steering hand activity(12-14 months)Visually interested in simple pictures(14-16 months)Often holds objects very close to eyes to inspect(14-18 months)Points to objects or people using words look or see(14-18 months)Looks for and identifies pictures in books(16-18 months),24 months to 36 months,Occasionally visually inspects without needing to touch(20-24 months)Smiles,facial brightening when views favorite objects and people(20-24 months)Likes to watch movement of wheels,egg beater,etc.(24-28 months)Watches own hand while scribbling(26-30 months)Visually explores and steers own walking and climbing(30-36 months)Watches and imitates other children(30-36 months)Can now begin to keep coloring on the paper(34-38 months)Reads pictures in books(34-38 months),40 months to 48 months,Brings head and eyes close to page of book while inspecting(40-44 months)Draws and names circle and cross on paper(40-44 months)Can close eyes on request,and may be able to wink one eye(46-50 months),4 years to 5 years:,Uses eyes and hands together well and in increasing skill Moves and rolls eyes in an expressive way Draws and names pictures Colors within lines Cuts and pastes quite well on simple pictures Copies simple forms and some letters Can place small objects in small openings Passes all the tests described in Important Observation Parents Can Make Visually alert and observant of surroundings Tells about places,objects,or people seen elsewhere Shows increasing visual interest in new objects and place,視覺注視,注視注意週邊聲音 2-4個月注意週邊物體 5-8個月注意斜向物體 8-10個月凝視,
