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 trong nhifng rdi nhiiu tdm ly difgc chdn dodn
nliieu nhdt d hge sinh trong dp tuoi de'n trudng, ddc biet Id d giai dogn ddn tieu hgc
khi 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 khi 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 ra tdng dgng, gidm chu y vd dita ra mpt sd kei qud nghien citu ve
khd khdn hgc dudng cua tre tdng dpng, gidm chu y trong giai dogn ddu lieu hgc ddn
thdi de xudt mpt sd ggi y trong 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,
trong 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 trong 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 trong
mdt Idp hgc cd 25 - 30 em tht cd thd cd mdt em dugc chin doin vdi tang ddng,
giam chu y. 6 Viet Nam, mdt sd nghien cOu vd sOc khoe tim than tre em tudi
TAP CHI TAM ly HOC, Sd 3 (168), 3-2013

69


den trudng tai Ha Ndi (tidn hinh bdi Benh vien Nhi Trung uong) cho bidt ty le
hgc sinh tO 4 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 trong 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 choa 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 nay din ddn nguy co ri't cao m i tre cd tang ddng,
giim chu y phai dd'i mat khi 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; do vay, viec di sau nghien cOu vi'n dd niy vi dua ra 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 con ngudi trong giai doan dit nude ta dang
trong thdi ky hdi nhap nhu hidn nay.
1. 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 ra tang ddng, giam ehu y. Tuy nhien gin day,
mdt nghien cOu da dua ra con 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 ra cung ed su khic biet vd cic dudi diy
than kinh, bach day, thd chai va su lien he giua hai bin ciu nay. Cic do ludng
vd mat sinh ly nao cho Ihay, nhung di'u hieu bit thodng trong Ion thdng miu d
phan nao trude cQng nho cic di'u hieu khac trong dudng lien he thin kinh giua
hai bin cau nio va he limbic. Cd mdt dieu dang Imi y la khi tic ddng bing
thudc thi cac da'u hidn bit thudng nay cung giam bdt (Carolyn S. Schroeder.
Betty N. Gordon, 2002).

70

TAP CHI TAM Ly HOC, Sd 3 (168), 3-2013


Cic bing chOng lim sang trong nghien cOu vd di truyen cho tha'y, gen
eung ddng mdt vai trd kha quan trgng trong 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 thanh cd tidn su chin doan tang ddng, giam chu y cd it nhi't mdt dOa con
cd ting ddng, giim chu y va 52% trong sd hg cd tO hai con trd len eung cd tang
ddng, giam chu y. Cdn ddi vdi nhOng ngudi cd anh hoac em cd rdi loan nay,

khi ning hg cOng roi vio didn rdi loan la 11% ddn 32% (Levy, Hay,
McStephen, Wood & Waldman, 1997). Nhung con sd niy se cao hon ddi vdi
nhOng Clip sinh ddi. Vdi nhung cap sinh ddi khae trOng, kha nang nay roi vio
khoang 29% ddn 38% cdn ddi vdi nhOng cap sinh ddi eung trOng thi ty le nay
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 con nudi va nhOng gia dinh
hgc sinh cd tang ddng, giim chu y li con de. Ket qui didu tra eho thi'y, chi cd
6% bd me nhiing hge sinh cd tang ddng, giim chu y li con nudi eung cd rdi
loan tuong ty trong khi dd, con 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 trong 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 nay.
Nhu vay, trong sd tit ca cic nguyen nhan dugc xem la can nguyen giy
ra 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 3 (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 6 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 do ciu
thi khi lim bai tip d trudng, d ndi lam vide hay trong cic hoat ddng khac.
b. Thudng khd duy 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 6
trudng, cic vide vat hoic cic nhiem vu khic (khdng phai do 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 duy 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 sao nhang bdi cic kich thi'ch ben ngoai.
i. Thudng dang tri trong 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 6 thing d mOc do kdm thieh nghi vi miu thuin vdi su
phat tridn cia tre:
Qud hieu dpng

a. Thudng eya quiy tay, chin hoac ca ngudi khi ngdi.
b. Thudng rdi khdi ghd trong lap hgc hoac trong nhung trudng hgp cin
ngdi d chd ed dinh.
^. Thudng chay hoic leo treo qui mOc trong nhttng tinh hudng khdng
phil hgp.

^2

TAP CHI TAM Ly HOC, Sd 3 (168), 3 - 2013


tTnh.

d. Thudng khd khan khi 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 ra ciu tra ldi trudc khi 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 7.
B. Sy suy ydu gay ra bdi eie trieu chOng nay phii bidu hien d it nhi't hai
mdi trudng khic nhau 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 trong cic
chOc ning xa hdi, hge tap va nghd nghiep.

D. Nhung trieu chOng khdng xuat hien rieng biet trong 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 khi 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 ra 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 khi cdn giy khd
ddt vdi nhOng ngodi khdng lam chuyen mdn trong 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 thanh

TAP CHiTAM LynOC, Sd3 (168), 3 - 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 do cd 10

can diu ndu len eie di'u hidu eua su giam chu y, 9 ciu tie'p theo md ti eac bidu
hien tang ddng va 8 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 do thudng
xuydn tO 1 den 5, trong dd 1 la khdng bao gid (hoac khdng ed, khdng dung) va
5 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 6 thdng qua, xin anhlchi eho biet con cda
anhlchi cd nhiing bieu Men ndo Irong sd nhiing bieu hien sau ddy?
(Khoanh trdn vdo mite dp tuang itng)
I = khdng diing; 2 = it khi; 3 = thinh thodng; 4 = thudng xuyen; 5 = rdt thudng
xuyen
MOc dd

STT

Cae bieu hien

1

Tre kho tap trung c h i y hoac rit bat can trong hgc tap
cung nhu nhimg cdng viec thucmg ngay

1 2

3

4

5

2

Tie khd khan khi phai duy tri su chu y cua minh vao mdt
cdng viec nao day

1 2

3

4

5

3

Luc trd chuyen, tre cd ve khdng ling nghe ldi ngudi ddi
thoai

1 2

3 4

5

4

Khi (anh) chi dan dd tre didu gi, tre td ra rit hidu va ghi
nhd nhung sau dd thi lai khdng hd thue hidn theo (khdng
phiii do khdng hidu ldi dan hay cd y chdng ddi)

1 2

3 4

5

5

Khi (anh) ehi giao cho tie mgt vide gi. Ire phai loay hoay
rat lau mdi cd thd bit dau cdng vide

1 2

3

4

5

6

Tre thudng xuydn danh mil dd dung cua minh

1 2

3

4

5

7

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

1 2

3

4

5

Tie dd bi sao nhang bdi nhflng am lhanh va lieng ddng
bdn ngoai

1 2

3 4

5

8

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TAP CHI'TAM l y HOC, Sd 3 (168), 3 - 2013

9

Tre thudng td ra lo dang trong hgc tap cling nhu trong cac
boat ddng hang ngay

1 2

3 4

5

10

Khi ndi chuydn, tre thudng xuydn chuydn tO mdt chu dd
nay sang mdt chu dd khac

1 2

3 4

5

11

Tre khd ngdi ydn hon so vdi cac ban cung tudi

1 2

3 4

5

12

Tre thich chay nhay va leo treo d ba't cO noi dau

1 2

3 4

5

13

Tre hoat ddng ludn tay ludn chan nhu duoc gin ddng co

1 2

3 4

5

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

1 2

3 4

5

15

Tre thudng nghich dai vi khdng ludng duoc nguy hiem

1 2

3 4

5

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

1 2

3 4

5

17

Tre thudng hay mic ldi khi thuc hidn cac cdng vide dugc
giao

1 2

3 4

5

18

Tre ndi nhieu

1 2

3 4

5

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)

1 2

3 4

5

20

Tre thudng rat khd khan khi tham gia cac hoat dgng tTnh
(choi cd vua, cat dan...)

1 2

3 4

5

21

Khi ehoi cac trd choi theo lugt (ca ngya, chay tidp sOc ..),
tre khdng the kidn tri chd dd'n luot eua minh

1 2

3 4

5

22

Tre hay ha'p tip, chua nghe xong cau hoi thi da tra 161

1 2

3 4

5

23

Tre chen ngang vao khi ngudi ldn dang noi chuyen

1 2

3 4

5

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

1 2

3 4

5

25

Tre td ra rat hung hang khi choi diia vdi cac ban

1 2

3 4

5

26

Tre rit dd gian du hoac mat kidm che

1 2

3 4

5

27

Tre cau ban va dd buc bdi

1 2

3 4

5

Vdi he sd eronbaeh anpha ti'nh duge Ii 0,883 (> 0,6), bang kidm dugc
xem la cd do tin cay cho phep; didm trung binh eua bang kidm la 2,9 vi do lech

TAP CHITAM Ly HOC, Sd 3 (168), 3 - 2013

75

ehuin luong Ong la 0,37. Khi su dung bang hdi nay dd tidn hinh sang Igc tren
948 hgc sinh cia 4 trudng tidu hgc tren dia bin thanh 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, 7 tre thude thd tang ddng - xung ddng chidm ou the vi 1 tre cd bidu hidn
cia rdi loan giam chu y trdi. 6 mdi didn rdi loan, sd lugng tre nam ed xu hodng
vugt trdi hon so vdi nO; trong dd, ehi ed 6 tre li nO, 38 tre cdn lai la tre nam - sd
logng trd nam nhidu gi'p 6 lin so vdi tre nO.
Bang kidm cia chung tdi chi duge sO dung trong dd tai va hien lai vin
chua dugc ehuin hda. Hy vgng ring trong thdi gian tdi, vdi nhttng nghien cuu
siu hon, ching tdi ed thd chuin hda dugc bing kidm cua minh dd nd dugc trd
thanh mdt cdng cu nghidn cOu cung nhu thue hanh trong chin doin va didu trj
tang ddng, giim chi y tai Viet Nam.
2. Mgt sd khd khan ma tre tang dgng, giam chu y gap phai khi gia
nhap mdi trudng hgc ducmg
Tre tang ddng, giam ehu y bit diu co nhttng bidu hien rd'i loan tO rit
sdm, khi tre bit dau chap ehttng bidt di vi thudng ro ban d giai doan miu giio.
Tuy nhien, phai den khi 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
thanh "nan de" khidn cho bd me eung nhu giao vien dau diu. Trong mdi trucfng
hge tip mdi, tre bit dau trd thanh 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 trong khi 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 trong 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 khi din de'n eac
thit bai hgc dudng eua cic em.
Cung trong 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 trong 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 do vdi thang didm tO 1 ddn 5 va dugc chia lam 2 nhdm: nhdm thO
nhit li nhOng khd khin trong 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:

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TAP CHI'TAM Ly HOC, Sd 3 (168), 3 - 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 trong dinh gii
giOa ca giio vien va phu huynh, xdp d eie vi tri 1, 2, 3 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
trong 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 trong cdc mon hgc ddi hdi sit kien tti
(DTBGv = 3,86: DTBPH = 3,23); "Tre thudng lung titng khi thuc hien cde hogt
dpng ddi hdi .sir kheo leo" (DTBGv = 3,78, DTBPH = 2,8). Ddi vdi nhung khd
khin cdn lai trong 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 trong dinh gii gitta hai nhdm khieh the nghien cOu

vdi mdt ben Ii giio vien va ben kia 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
trong danh gii gitta phu huynh vi giio vien d diy khdng cho thiy sy khic biet
trong tinh chit eia eac chi bio ma ehi eh! ra eho chung ta thay mOc do uu tidn
vi sy quan tam khae nhau dd'n cic vi'n dd hge dudng cia tie d hai khach thd
tren.
3. Mgt sd ggi y can thiep va tri lieu
3.1. Nhiing nguyen tdc chung khi 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 duy nhi't ma nd tdn tai gin nhu
thdng nhit d cic mdi tru&ng khac nhau cho du dd li 6 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 do 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... trong 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 nhau
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 trong kha ning ty kiem
che, hudng tdi dieu ehinh nhttng bidu hien khdng phu hgp cho tre a hien tai va
trong tuong lai.

TAP CHi TAM Ly HOC, Sd 3 (168), 3-2013

77


Mgt ydu td khic cin phai luu y khi 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 ra d
nhOng thdi didm trong 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 sao nd ed thd dude ip dung trong nhidu mdi trudng khic nhau. 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 ra trong 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 trong
bdi cinh eia phdng khim tim ly mi nhat thidt phai duge thye hien trong ci
nhOng mdi trudng thudng nhat nhu d nhi hay d tru&ng. Chinh vi ly do 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 khi 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 do kho khin nhu ban diu. Kinh nghiem thyc te eua chOng tdi trong
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 thanh nien, viec
can thiep se khd ban ri't nhidu. Sau diy la mgt vii ggi y trong viec can thiep va
tn lieu cho tre ting dgng, giim ehu y danh eho bd me va giao vien. Mdt khi 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 trong 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

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TAP CHI'TAM Ly HOC, Sd 3 (168), 3 - 2013


Vide tip huin cho bd me trong 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 nay ndn
duge didn ra trudc khi qua trinh can thiep cho tie duoc thyc su bit diu. Mdt khi
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 trong tn lieu
cho tre tang ddng, giam chu y do 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 ngay
chinh con cia hg trong nhOng tinh hudng cu the vi trong 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

nhau. 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 trong hai mdi trudng chi dao cd inh hudng khi 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 ngay trong 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
trong 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 khi bit dau thye hien boat ddng; (3) Ludn dua ra
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 3 (168), 3-2013

79


trudc khi 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 nhau 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 nhau 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 khi cic em thyc hien doge mdt hanh vi phu hgp
(vi du nhu cho phep tre ra 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 sao 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 khi thyc hidn dung didu giio vien yeu ciu. Cdn khi 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 nhau.
Mgt trong 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 nay dac
biet phu hgp vdi nhOng tre ldn. Giio vien va hoe sinh cung thao mdt ban thoa
thuan, trong dd ed ghi ro: cic hanh vi hay nhiem vu ma tre phai hoin thanh
hoic thyc hien dugc va nhOng phin hdi (sy cing cd) giio vidn se doa ra.
Tai lieu tham khao
1. American Psychiatric Association, Diagnostic and statistical manual of
mental disorders: DSM-N-TR, Fourth edition, 2000.
2. Barkley R.A. & Mash E.J.. Child Psvpatlioloi>y. Guilford Press, NewYork,
1996.
3. 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.
4. 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 3 (168), 3 - 2013


study. Journal of the American Academy of Child and Adolescent Psychiatry,
36,tr. 737-744, 1997.
5. Schroeder Carolyn S. & Gordon Betty N., Assessment & Treatment of
Childhood Problems - A Clinician's Guide. Guilford Press. NewYork. 2002.

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