國小腦性麻痺孩童學校參與影響因子

The Determinants of Primary School Participation in Children with Cerebral Palsy

黃千瑀(Chien-Yu Huang)

指導教授 ： 曾美惠

國立臺灣大學/醫學院/職能治療研究所/碩士(2010年)

https://doi.org/10.6342/NTU.2010.01127

摘要

研究背景與目的
腦性麻痺孩童常因動作控制困難或伴隨其他障礙而影響學校生活的參與，進而影響其學習及未來的社會適應。因此，促進腦性麻痺孩童的學校活動參與是醫療與教育人員的共同目標。影響腦性麻痺孩童學校活動參與的因素包含多面向，包括孩童的特質（身體功能與構造，功能）以及環境因素，然而，目前尚無研究囊括多面向因素來探討與腦性麻痺孩童學校活動參與的關係，因此，本研究將同時探討腦性麻痺孩童的功能與環境因素，從多面向的角度來探討腦性麻痺孩童學校活動參與影響因子。
研究方法
研究樣本為全台各縣市國小、特殊學校及腦性麻痺協會以及醫院復健門診之腦性麻痺國小學童。研究參與者納入條件包括：(1)國小腦性麻痺學童，(2)主要照顧者與學校老師同意參與研究。排除條件包括：(1) 若學童為在家教育，不符合學校生活情境，(2)主要照顧者無法以國台語溝通，或無法讀寫中文。研究工具為學校功能量表(School Function Assessment, SFA)，請學校老師填寫以了解學童學校表現。SFA共分成三部份，其中第一部份「學校活動參與」及第三部份「學校任務表現」將用於本研究，分別評量學童之活動參與程度及學校生理、認知/行為任務表現。其他變項涵蓋孩童的身體功能與構造、活動與參與及環境因素等層面，以訪談家長或請家長、老師填寫相關問卷來蒐集。分析方法為先以多元逐步迴歸(Multiple Stepwise Regression)建立學校參與、從事學校肢體及認知行為任務表現三迴歸模型，找出其影響因子，其中，依變項分別為SFA第一及第三部分，獨立變項則為身體功能與構造、活動與參與及情境因素等變項。並進一步以路徑分析將此三迴歸模型結合，建立腦性麻痺孩童學校參與學校參與預測模型。
結果
共128位取樣自全台各縣市65間國小、4間特殊學校以及臺大醫院門診之腦性麻痺國小學童(平均年齡為9.88歲，標準差為1.96；68男童，60女童)。路徑分析顯示學校活動參與會直接受到三個因子影響，分別為孩童在學校肢體、認知/行為任務的表現，以及腦性麻痺的類型，而學校肢體任務及認知任務的表現又各有其影響因子，路徑分析模型適配度尚可(GFI = 0.98, AGFI = 0.91, CFI = 1.00, RMSEA = 0.000, x2 = 17.43, df = 25)。學校肢體任務的影響因子包括認知/行為任務的表現、日常生活功能、過動情況、下肢偏癱、動作障礙的嚴重程度以及學校大小；學校認知/行為任務表現的影響因子則包括日常生活功能、母親的國籍、智能受損、父母的社經地位、社交技巧、正向社會行為、學業表現以及在學校為接受特殊教育。影響學校的肢體任務表現及認知/行為任務表現的因子，則透過學校的肢體任務表現及認知/行為任務表現間接影響孩童的學校參與情況。此三迴歸模型分別解釋73%、85%以及79%的總變異量。
結論
此研究結果可協助醫療與教育工作者瞭解腦性麻痺孩童學校參與的影響因子，並建立腦性麻痺孩童學校參與之模型，包括結構和測量模型，且提供醫療與教育工作者介入之參考，期待透過改善這些影響因子以促進腦性麻痺孩童的學校參與。

關鍵字

腦性麻痺 ； 學校活動參與 ； 影響因子

並列摘要

Background
School participation in children with cerebral palsy (CP) is often restricted due to their motor impairments or accompanied disturbance of cognition, sensory, etc, which further affect their knowledge learning and socialization. Thus, for children with CP, the ultimate goal of rehabilitation and education is to facilitate their participation in school. The determinants of the school participation in children with CP encompassed multiple dimensions, including children’s functioning and contextual factors. However, to our knowledge, no study investigated the determinants of participation in school activities from multiple dimensions. Therefore, the aim of the study was to investigate the determinants of participation in school activities from a holistic view, including functioning and contextual aspects.
Method
Participants were 128 children with CP (mean age 9.88, SD 1.96) recruited from the following facilities: (1) 3 pediatric rehabilitation clinics, (2) 65 primary schools and 3 schools of special education, and (3) 2 Cerebral Palsy Associations. Inclusion criteria were (1) school-aged students, and (2) consents given from caregivers and school teachers. Exclusion criteria included (1) homeschooled children, and (2) caregivers who can not communicate/read in Chinese.
School participation and performance of both physical and cognitive/behavioral tasks were measured by the School Function Assessment (SFA). A range of variables related to children’s functioning, including body function and body structures, activity and participation, as well as context factors were measured by appropriate tools as the predictors of school participation. The determinants of school participation and performance of both physical and cognitive/behavioral tasks of children with CP were investigated using multiple stepwise regression models. Path analysis was used to explore the relationships between those three regression models, and build a path model of school participation.
Results
The final path model revealed that school participation was direct influenced by the performances of both physical and cognitive/behavioral tasks, as well as affected parts of CP. There were 6 determinants of the performance of physical tasks, including affected parts of CP, GMFCS level, hyperactivity, school size and daily function. The determinants of the performance of cognitive/behavioral tasks were daily function, mother’s citizenship, intellectual impairment, socioeconomic status, prosocial behaviors, social skills, receiving special education as well as academic performance. The determinants of performance of both physical and cognitive/behavioral tasks indirectly influenced the school participation. The three regression models explained 73%, 85%, 79% of the total variances respectively.
Conclusion
School participation was directly influenced by the performances of physical and cognitive/behavioral tasks, and affected parts. Both performances of physical and cognitive/behavioral tasks were respectively affected by variables related to body structure/function, activity, and contextual factors which indirectly influenced the school participation. Thus, intervention targeted at those factors may help children with CP to be better integrated into school. Besides, there are three concepts in school participation, including school attendance, participation in activities, social participation. As the SFA measured participation in activities which is only one aspect of the whole concept of school participation, further study on the determinants of social participation in school is warranted.

並列關鍵字

Cerebral palsy ； Participation in school activities ； Determinants

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