「國際功能分類系統」在動作發展遲緩嬰幼兒之應用

Application of “International Classification of Functioning, Disability, and Health” (ICF) to Infants and Toddlers with Motor Delay

黃靄雯(Ai-Wen Hwang)

指導教授 ： 廖華芳

國立臺灣大學/醫學院/物理治療學研究所/博士(2008年)

https://doi.org/10.6342/NTU.2008.00428

摘要

「國際功能分類系統」(ICF)與國際功能分類系統-兒童及青少年版」(ICF for Children and Youths; ICF-CY)分別於2001年與2007年由世界衛生組織正式發行。其內容包括「健康情形」(Health Condition)、「身體功能及構造」(Body Functions and Structures, b, s)、「活動及參與」(Activities and Participation, d)、「環境因素」(Environmental Factors, e) 及「個人因素」(Personal Factors) 五個部份。此外，ICF 及ICF-CY均已出版詳細之類目(categories)用以描述個人之健康狀況(Health Status)。與ICF相關之研究分為兩個層次：概念層次(conceptual level)與計畫層次(programmatic level)。概念層次之研究著重於ICF之架構及其各部分之關係；計畫層次之研究則著重於類目之應用。其中「環境因素」與「個人因素」統稱為「情境因素」(Contextual Factors)。ICF架構強調b, s, d 是「健康情形」與「情境因素」互動的結果；但此概念層次於遲緩兒童方面，尚無實證資料佐證。且為促進ICF之臨床實用性，針對各項成人疾病已有短版由二級類目組成之核心項目組(ICF Core Set)；然而，在動作發展遲緩嬰幼兒此計畫層次之文獻尚缺乏。因此，針對動作發展遲緩嬰幼兒，本研究分為兩部份探究ICF-CY概念層次與計畫層次之可行性。第一部份(概念層次)目的，利用理論及實證資料，以三個不同動作功能 (靜態姿勢維持能力、基本移動能力及視覺動作整合能力)為d部分之成果指標，分別提出三個適用於動作發展遲緩嬰幼兒以ICF-CY架構為基礎之假設模型，並收集資料驗證三個假設模型之正確性。第二部份(計畫層次)目的，則針對動作發展遲緩嬰幼兒提出ICF-CY核心項目組之可能類目。
方法：第一部分：先針對六個主題進行系統性文獻回顧，以確立可代表ICF-CY架構中各部份的重要變項及測量，並建構三個動作指標假設模型。接著，以方便取樣，共有70名6-24個月動作發展遲緩嬰幼兒及其家庭完成所有ICF-CY五部份主要相關測量變項，包括：(1)兒童之動作嚴重度(健康情形)、(2)兒童之身體功能(智力功能(b117)、動機(b130)、視覺(b210)、肌力(b730)、肌張力(b735)、肌耐力(b740)、平衡反應(b755))、(3)兒童之活動(皮巴迪動作量表第二版之靜態姿勢維持能力分量表(d410, d415)、基本移動能力分量表(d450, d455)、視覺動作整合能力分量表(d440))、(4)環境，包括家庭之環境與社會服務符合需求程度(屬家庭物理環境之玩具與器具(e115)及家中物理環境之安排(e155)、屬家庭社會環境之家庭支持與關係 (e310)及家庭成員之因應策略(e410)、社會服務符合需求程度(e5))、(5)個人因素，包括年齡與性別。以部分樣本檢驗各測量之信度。最後，將具信效度之變項，以兒童個人因素(年齡、性別)為共變項，使用MacArthur moderator-mediator approach來進行資料分析，alpha值設在0.05，以驗證三個假設模型之正確性。第二部分：由11名來自於不同早期介入背景之專家參與，專家們藉由第一部份之研究所得動作遲緩嬰幼兒於25個類目的問題比率 (problem rates)，選出那些類目可能為ICF-CY核心項目組。最後，完全符合以下兩個條件則為可能的核心項目組類目：(1) 80%以上專家之認可，及(2) 30%以上動作遲緩嬰幼兒在該類目有問題。
結果及討論：概念層次部分：根據資料分析，本研究提出三個ICF-CY模型。於三個ICF-CY模型中，家庭社會性環境之「家長參與程度」(e310)為「健康情形」與部分「身體功能」(b117, b755)間的中介變項；而家庭物理性環境，如「家中空間設施及規劃」(e155)、玩具及學習材料(e115)則與「健康情形」同時預測基本移動能力或視覺動作整合能力；大部分「身體功能」變項(b)是「健康情形」與「活動及參與」(動作功能)(d)間之中介變項。動作發展遲緩嬰幼兒之動作嚴重度(健康情形)會影響「活動及參與」(d410, d415, d440, d450, d455) 及「身體功能」(b117, b130, b730, b735, b740, b755)。「家庭調適」(e410)與家庭符合需求程度變項(e5)則與三個動作活動無顯著相關。本研究結果支持ICF-CY架構，於介入計畫中應重視家庭環境，此外，「身體功能」(b)對「活動」(d) 影響大，因此於臨床介入目標應同時考慮「身體功能」、「活動」與家庭環境三個部份。計畫層次部分之結果顯示，本研究所連結之ICF-CY的25個類目中，有20個類目被80%以上專家同意為核心項目組，本研究30%以上動作遲緩嬰幼兒在21個類目呈現問題；兩者之類目並不完全一致；最後，有17個類目同時具備兩者之標準。因此，本研究提出動作遲緩嬰幼兒之ICF-CY核心項目組之17個可能類目如下：(b117) 智力功能、(b130)能量和驅力功能、(b755) 不隨意動作反應功能、(d310)溝通—接受口頭訊息、(d330)說、(d410)改變身體姿勢、(d415)保持身體姿勢、(d430) 舉起和搬運物體、(d440)手的精巧使用、(d450) 步行、(d455) 到處移動、(d550) 吃、(d560) 喝、 (d710) 基本人際交往、 (e115) 個人日常生活用品和技術、 (e310) 直系親屬家庭、 (e5) 服務、體制和政策。然核心項目組之確實類目還需更大樣本與更多專家達成共識，才可能於臨床應用。
臨床應用: 相較於動作發展遲緩嬰幼兒之「健康情形」及「個人因素」，「身體功能」及「環境因素」在ICF-CY中，是較容易因早期介入而改變的。此研究所提出之「身體功能」及「環境因素」的重要中介或預測變項，可作為早期介入服務目標之依據。本研究所提出之動作遲緩嬰幼兒之17個核心項目組之可能類目，可以為功能描述與分類之參考。結論：本研究提出三個ICF-CY模型，原則支持ICF-CY架構，可以為臨床決策之參考。此外，17個類目可能為動作發展遲緩嬰幼兒之核心項目組，可為臨床功能分類之用。

關鍵字

動作發展遲緩 ； 國際功能分類系統 ； 國際功能分類系統-兒童版 ； 兒童發展 ； 國際功能分類系統-兒童版核心項目組

並列摘要

The International Classification of Functioning, Disability and Health (ICF) has been officially published in 2001, and the ICF for Children and Youths (ICF-CY) was also published in 2007. The framework of ICF and ICF-CY contains five components: Health Condition, Body Functions and Structures (b, s), Activities and Participation (d), Environmental Factors (e), and Personal Factors. The Environmental Factors and Personal Factors are grouped into the part of Contextual Factors. At conceptual level, the framework emphasized that the Body Functions (b) and Structures (s) and Activities and Participation (d) are the results of the interactions between Health Condition and Environmental Factors (e). At programmatic level, to facilitate the use of ICF in clinical practice, the whole ICF version has been condensed into several different ICF Core Sets for different adult diseases. Only a few ICF categories in the ICF Core Set are needed to describe the health –related status of one person with a specific disease. However, the literature about the application of ICF-CY for both conceptual level and programmatic level were limited in infants and toddlers with or risk for motor delay (WMD). The purposes of this study were: (1) To establish and test the hypothetical ICF-CY based models for explaining motor development (Activities and Participation) in infants and toddlers WMD younger than 2 years (conceptual level). (2) To finding the potential categories for ICF-CY Core Set for infants and toddlers WMD (programmatic level).
Methods: the present research was divided into two parts: Study I (conceptual level research) and Study II (programmatic level research). For Study I, firstly, 6 relevant topics in ICF components were systematically reviewed, and related variables and measures were selected. Secondly, reliability of the selected measures was examined in part of children enrolled in present study. Thirdly, to construct three hypothetical ICF-CY based models based on three motor outcomes (Stationary, Locomotion, and Visual-motor integration). A convenient sample of children WMD (n=70) aged 6-24 months was collected. All the enrolled children and their families received measures to have variables related to 5 components of ICF-CY: (1) Motor severity (Health Condition); (2) Body Functions ((b117) Intellectual Functions, (b130) Mastery Motivation, (b210) Seeing Functions, (b730) Muscle Power Functions, (b735) Muscle Tone Functions, (b740) Muscle Endurance Functions, (b755) Balance)); (3) Activities (Stationary (d410, d415), Locomotion (d450, d455), and Visual-motor integration subtests (d440) in Peabody Developmental Motor Scales 2nd Edition (PDMS-II)); and (4) Environmental Factors (learning material or equipment at home (e115), physical home environment arrangement (e155), relationships and support of immediate family (e310), family coping strategies (e410), needs or social support (e5)); and (5) Personal Factors (age and sex). MacArthur moderator-mediator approach was used to analyze the data and verify the three ICF-CY based hypothetical models while the alpha level was set at 0.05. In study II, 11 experts from multi-disciplinary backgrounds in early intervention were invited to attain the consensus on potential 2nd level categories of ICF-CY Core Set for infants and toddlers WMD. The problem rates of the categories in study I and the questionnaire were sent to the experts to obtain their consensus of potential categories of ICF-CY Core Set. The categories in the ICF Core Sets were determined when both of the following criteria were met: of >80% consensus from experts and of >30% of the sample in study I presenting problems on specific categories.
Results: for study I (conceptual level), we proposed three ICF-CY models for 3 motor outcomes. Among the three models, social Environmental Factor (“Involvement” (e310)) could be the mediators between the Health Condition (Motor severity) and (b117and b755)) in Body Functions; another social Environmental Factor (“Responsivity” of parents (e310)) could be the mediators between the Health Condition (Motor severity) and one Body Functions variable (b117); one physical Environmental Factor (“Inside space” (e155)) together with Motor severity could predict Locomotion DA (d450, d455); another physical Environmental Factor (“Fine motor Toys”, and “Learning material” (e115)) together with Motor severity could predict Visual-motor integration DA (d440); Health Condition (Motor severity) could predict Activities and Participation (three types of motor outcomes) and Body Functions; some Body Functions variables (b117, b130, b730, b735, b755, b740) could be the mediators between the Health Condition (Motor severity) and Activities (Stationary DA (d410, d415), Locomotion DA (d450, d455), or Visual-motor integration DA (d440)). One more complex mediating path may exist: Motor severity would affect “Involvement” (e310), and then “Cognitive DQ” (b117) and “Balance” (b755), and then three motor outcomes (Stationary DA (d410, d415), Locomotion DA (d450, d455) and Visual-motor integration DA (d440)). Distal Environmental Factors (“Family coping strategies” (e410), and “Met needs index” of family (e575, e580, e585)) were not correlated with three motor outcomes in all three derived models.
For study II (programmatic level), according to the results of survey, 20 of the 25 selected ICF-CY categories have reached >80% consensus from experts; 21 have reached >30% problem rates. 17 of the 25 selected ICF-CY categories had met both criteria to be potential ICF-CY Core Set categories. Those categories were: (b117) Intellectual Functions, (b130) Energy and Drive Functions, (b755) Involuntary Movement Reaction Functions, (d310) Communication with-receiving-spoken message, (d330) Speaking, (d410) Changing Basic Body Position, (d415) Maintaining a Body Position, (d430) Lifting and Carrying Objects, (d440) Fine Hand Use, (d450) Walking, (d455) Moving Around, (d550) Eating, (d560) Drinking, (d710) Basic interpersonal interaction, (e115) Product and Technology for Personal Use in Daily Living, (e310) Immediate Family, (e5) Services, Systems, and Policies.
Conclusions: At the conceptual level, specific 1 to 2 social Environmental variables could mediate the relationship between Health Conditions and Body Functions or between Health Conditions and Activities; specific physical Environmental Factors as well as Health Condition could predict Balance functions in Body Functions, and could also predict Locomotion and Visual-motor integration in Activities; most of the variables in Body Functions could be the mediators between Health Condition and Activities. At programmatic level, there are slight differences of the possible ICF-CY core categories between consensus of experts and evidence from empirical data for infants and toddlers WMD. The potential categories for ICF-CY Core set for Infant and toddlers WMD were also slightly different from the ICF checklist designed for adults.
Clinical implications: The present study indicated the mediating processes of the variables in Body Functions and Environmental Factors would provide the most relevant elements for interventionist to begin with. The potential 17 ICF-CY categories would provide for establishing ICF-CY Core Sets and would help the clinicians to classify and describe the Health Status for infants and toddler with or at risk for motor delay.

並列關鍵字

Motor Delay ； ICF ； ICF-CY ； Child development ； ICF-CY Core Set

參考文獻

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