【作者】 贾兆宝；

【导师】 田文华；

【作者基本信息】 第二军医大学 ， 社会医学与卫生事业管理， 2013， 博士

【摘要】 研究背景和意义2008年5月12日，四川省发生了里氏8.0级强烈地震。这次地震危害极大，遇难69227人，受伤374643人，失踪17923人，其中遇难和失踪的学生共计5335名，共造成四川省152万名城乡劳动者失业、失地，直接经济损失达8452亿元。如何从科学的角度帮助受灾群众重建家园，是灾区社会重归和谐的基础。心理重建，作为灾后重建的重要组成部分，得到了我国政府和各社会团体的高度关注。然而，目前大多数灾后心理援助的技术和方法都来自境外，对其是否符合中国人的特点，尚需要研究。加之，从国际范围来看，对灾难发生后儿童和青少年的心理学和社会流行病学研究还非常少。汶川地震中的儿童和青少年不但遭受身体上的严重损伤，在心理、精神以及社会关系上都受到巨大创伤，这使我国完全有条件在该领域做出独特的贡献，总结出一套切实可行、符合中国国情的心理援助模式。研究方法和内容本研究以中国汶川地震为背景，阐述了灾后儿童和青少年心理危机现状和发展趋势，剖析了我国灾后心理援助工作存在的问题，并在实证的基础上提出了完善灾区儿童和青少年心理援助工作的对策和建议。具体可分为理论研究、实证研究和对策研究等三个方面。首先，理论研究总结了地震后儿童和青少年心理危机的表现、发生机制、主要类型和诊断标准，以及地震后儿童和青少年心理危机干预的目标、模型和实践方法。其次，实证研究分析了汶川地震后儿童和青少年心理危机和生命质量随访研究结果，以及汶川地震后儿童和青少年心理卫生服务利用和社会支持状况。第三，对策研究论述了汶川地震后儿童和青少年心理危机高危人群的特点，并且就如何完善汶川地震后儿童和青少年心理卫生服务供给策略和个体心理危机干预策略做了深入讨论。主要研究结果心理危机方面，灾后第1年至第3年，灾区儿童创伤后应激障碍（PTSD）和抑郁的流行率未发生明显改变，分别维持在10%和13%以上，特别是遭遇严重受伤、丧失亲人或者其他对自己非常重要的人等创伤的群体PTSD和抑郁的患病率均高达20%以上。回归分析显示，丧失亲人的儿童最易患PTSD和抑郁，其患病可能性分别是未丧失亲人群体的6.6和4.1倍。以上研究结果表明汶川地震后灾区儿童和青少年PTSD和抑郁患病已相当普遍，平均每10人中就有1～2人患病。综合PTSD患者自杀危险性一般估计（13%），仅重灾县的340万受灾学生中，34万可能患PTSD，其中4.4万人有自杀的危险性。生命质量方面，灾区儿童和青少年生命质量总分以及各维度生命质量得分均低于国内儿童生命质量平均水平。灾后第1年至第3年，灾区儿童和青少年生命质量显著下降，其中生命质量总分下降2.0、学校功能得分下降4.6。PTSD患者、抑郁患者生命质量得分随时间分别降低6.4、6.7，而非PTSD患者、非抑郁患者生命质量得分并未表现出明显的随时间变化的趋势。PTSD和抑郁是影响灾区儿童和青少年生命质量的最重要因素，PTSD或抑郁每1分值的变化都会引起生命质量0.3～0.5的反向变动。心理卫生服务利用和社会支持方面，研究发现心理卫生服务利用率从初次调查的34.6%跌至随访调查的9.5%，更重要的是，PTSD患者、抑郁患者心理卫生服务利用率始终在低位徘徊（10%～25%），即大多数PTSD患者、抑郁患者没有利用任何形式的心理卫生服务。社会支持能有效降低灾区儿童心理危机发生概率和严重程度。卫生政策建议本研究建议，灾后心理重建工作在抚慰重要创伤经历人群的基础上，应逐渐关注间接暴露群体、少数民族、女性和茂县居民。同时，鉴于灾区儿童和青少年灾后心理健康状况严峻，波及范围和涉及人数规模巨大，且因客观因素制约，如灾区高度短缺心理援助资源、有关机构无力继续灾区心理援助计划等，建议参考部分国家自然灾害后成熟的心理援助模式，将此问题上升到国家层面来考虑和应对，建立由国家主导的可靠的灾区儿童和青少年心理援助长效机制，并使其成为今后常设的减灾救灾机制的一部分。具体包括建立国家主导的灾区多层次的儿童和青少年心理援助体系、培育专业的心理卫生服务队伍以及建立长期心理卫生档案随访制度等。在个体心理危机干预中，要克服单一心理治疗或者艺术治疗的缺陷，建立一个多学科和多层次合作的服务和研究团队，采取“心理—社会—文化”的综合干预模式，建立灾后儿童和青少年心理评估和干预机制。更多还原

【Abstract】 Background On May12,2008, a powerful earthquake measuring8.0on the Richter Scale struck Sichuan province, China. More than69,200people were confirmed dead, more than374,600were seriously injured, and more than17,900were reported missing, making it one of the deadliest natural disasters in history. Schools collapsed, over5,300children were confirmed dead or missing, the direct economic loss reached up to845billion. It is critically important to help the survivors rebulid their community in a scientific way. As an indispensible part of rebuilding, mental-health-rebuilding has been paid with great attention by the government and other social groups. Nevertheless, the majority of psychological support techniques are from abroad, and their application in China has not been proved. In addition, from an international perspective, epidemiological and psychological researches after disasters are little. Thus, the occurrence of Sichuan earthquake lend us a precious opportunity to investigate problems with the mental-health-rebuilding process, and make contributions in the areas of disaster-related psychological rescue.Methods The research discussed the status quo and developing trend of mental crisis for child and adolescent survivors, examined the problems with disaster-related psychological rescue, and proposed suggestions for improving the work of mental-health-rebuilding in Sichuan earthquake. The research could be divided in three parts as follows. First, the theoretical study summarized the manifestations, developing mechanisms, categories and diagnostic standards of child mental crisis, and concluded the objectives and techniques of child mental crisis interventions. Second, the field study showed the mental health and quality of life among child survivors of Sichuan earthquake, and investigated mental health care utilization and social support situation among them. Third, health policy research discussed the characteristics of high-risk populations, and suggested possible ways to improve the provision of mental health services.Results From the1st to the3rd year after the earthquake, there were no significant changes in the prevelances of both PTSD and depression, which remained above10%and13%, respectively. For those who had been badly hurt, had lost family members or significant others, the prevalences of PTSD and depression went up to20%. The regression analysis showed that the loss of family members is the biggest contributor for the occurrence of PTSD and depression, with OR at6.6and4.1 respectively. The above results suggested that mental health symptoms prevailed among surviving children, with almost1-2positive in10. When combining the suicide rate (13%) of PTSD patients, the research estimated that44,000students suffered from suicide risk out of the3.4million students in the severely affected areas.As to the child quality of life, the research found that quality of life scores among the child and adolescent survivors are beneath the national average. From the1st to the3rd year after the earthquake, child witnessed a marked decline of quality of life scores, at2.0for the overall scores and4.6for school functioning scores. PTSD and depression patients also reported lower scores over the time, while non-PTSD and non-depression patients almost remained the same. The regression analysis showed that PTSD and depression were the biggest contributors of quality of life, and one point increase in PTSD or depression would result in0.3-0.5decline of quality of life scores.The disaster area also witnessed a significant decline of mental health service utilization among the child and adolescent survivors, with34.6%in the1st year and9.5%in the3rd year. Moreover, the utilization rate of PTSD and depression patients staggered around10%-25%, which meant that the majority of the patients had not utilized the services. The study also found that social support could decrease the risk of mental health symptoms among these children.Policy implications The study suggested that, psychological support after disasters should focus on not only the groups with traumatic experiences, but also the indirect exposure group, minorities, female and Mao residents. Considering the critical mental health situation confronted by the children, as well as factors such as the shortage of human resources for psychological support, many social groups could not continue their work in the disaster area, the study proposed to establish a nation-managed support system based on the reference of successful examples in other countries, and to make it as a regular section of disaster relief in the next days. Concrete measures included the establishment of multi-level psychological support system, the development of professional human resources for psychological support, and the formation of mental health profiles for these children. As to individual interventions, to overcome the shortcomings of an isolated measure, the study suggested an integrated model of psychology support, social support and culture support.更多还原