學齡前發展協調障礙兒童之情緒行為問題預測因子

The Predictors of Emotional and Behavioral Problems in Preschool Children with Developmental Coordination Disorder

陳玉蘭(Yu-Lan Chen)

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(2012年)

https://doi.org/10.6342/NTU.2012.02628

摘要

研究目的：協調的動作能力是兒童學習和發展的基石，也是幼兒發展的重要預測指標。發展協調障礙 (Developmental Coordination Disorder, DCD)乃在動作協調發展上有明顯障礙，但排除有腦性麻痺、半癱、肌肉萎縮、廣泛發展性疾患等相關診斷。在美國，約有6％的5-11歲孩童有此問題。過去研究發現有高比例(43%~62%)的DCD兒童合併有情緒及行為問題，例如沮喪、焦慮等情緒問題或是注意力缺損、高活動量等行為問題，遠高於正常兒童的比例(5% ~12%)。然而這些研究以學齡期兒童或青少年為主，至今尚無研究探討學齡前DCD兒童的相關問題，使其問題易因累積而成為情緒行為問題的高危險群。國內外也還沒有相關研究從DCD學齡前兒童的內化情緒問題及外化行為問題完整的探討其情緒與行為問題及相關預測因子。本研究的目的即欲探討學齡前DCD兒童與正常發展兒童在情緒行為問題上的差異性，及更進一步探討其預測因子。

研究方法：研究對象為排除有腦性麻痺、半癱、肌肉萎縮、廣泛發展性疾患等相關診斷之3歲0個月至5歲11個月學齡前兒童。共分為兩組，一為DCD組，即在台灣北、中、南22家幼稚園及托兒所及台北地區兩家醫學中心，由老師或家長轉介懷疑有動作協調問題之學齡前兒童1680位，以學齡前發展協調障礙評估量表中文版(Little Developmental Coordination Disorder Questionnaire, LDCDQ)篩檢後疑似有動作協調問題兒童為170位。另一為控制組：即年齡、性別與疑似有動作問題兒童組配對之正常發展孩童170位。再由治療師施測兒童動作能力測驗第二版(Movement Assessment Battery for Children, 2nd ed., MABC-2)以確認是否有DCD，最後有86位DCD組及56位正常組(typically developing children, TD) (正常組皆為社區個案)納入研究。家長填寫基本資料表、一歲半至五歲兒童行為檢核表(Child Behavioral Checklist - Chinese version 1.5-5, CBCLC/1.5-5)、中文版文蘭適應量表之日常生活功能次分項(Daily living skills subscale of the Vineland Adaptive Behavior Scale - Chinese version ,VABS-C)及親職壓力量表短版(Parent Stress Index-Short Form, PSI-SF) 以評量兒童之情緒和行為問題，日常生活功能及主要照顧者親職壓力。以T檢定探討學齡前DCD兒童與正常兒童在情緒行為問題的差異性。以多元迴歸分析探討學齡前DCD兒童的情緒行為問題預測因子。其中，依變項為DCD兒童情緒行為問題的內外化分數，獨立變項為DCD孩童的個人因素(年齡、性別、生產過程中遭遇困難(例如缺氧、產程困難、機械性的傷害或是顱內出血)、兒童動作障礙的程度及日常生活功能)及環境因素(出生順序、家庭社經地位指數、兒童出生時母親的年齡、主要照顧者親職壓力)。

結果：結果顯示學齡前 DCD兒童比正常發展兒童有更顯著的情緒行為問題：包括內化問題internalizing ( t=4.76, p<0.001)及外化問題externalizing (t=5.96, p<0.001)。在CBCL-C/1.5-5的七個症候群中，除了身體抱怨(Somatic Complaints) (t=1.22, p=0.22)外，DCD兒童皆比正常發展兒童嚴重，且達顯著差異。DCD兒童與正常發展兒童的情緒行為問題落於臨床範圍的比例為：CBCL-C總分 (32.6% (DCD) vs. 3.5% (TD))，內化問題 (34.9% (DCD) vs.10.7% (TD))，外化問題 (26.7% (DCD) vs. 1.7% (TD))。超過一半的DCD兒童(57 %)至少有一種CBCL-C/1.5-5症候群落於臨床範圍，遠高於正常兒童的比例(12.5%)，其中最常見的問題為畏縮(Withdrawn behavior : 38.4%)，注意力問題(Attention problems : 24.4%)和情緒反應問題( Emotionally Reactive : 23.3%)。DCD兒童情緒問題之預測因子為親職壓力及精細動作能力障礙嚴重度，行為問題之預測因子包括親職壓力、社經地位及性別。當主要照顧者承受越高的親職壓力或是兒童本身有越嚴重的精細動作能力障礙，DCD兒童就會發生越嚴重的情緒問題；此外，當主要照顧者承受越高的親職壓力或是越低的家庭社經地位及男性DCD兒童，其行為問題也會越嚴重。

結論：本研究結果顯示，除了動作問題外，臨床工作者及老師還必須注意學齡前DCD兒童的情緒行為問題，尤其是畏縮、注意力及情緒反應問題。並針對情緒行為的預測因子包括性別、高親職壓力、低社經地位、兒童精細動作能力障礙等及早訂定有效的介入計畫，例如提供支持性團體或教導適應策略以減輕主要照顧者的親職壓力，加強訓練兒童精細動作能力等，進而改善兒童之情緒行為問題。對於低社經地位或男孩DCD兒童，也須更注意其行為問題，讓DCD兒童更能參與社會，過有意義的生活。

關鍵字

發展協調障礙 ； 情緒及行為問題 ； 預測因子 ； 學齡前孩童

並列摘要

Objectives: Developmental Coordination Disorder (DCD) is a marked impairment in the development of motor coordination in children that cannot be attributed to a general medical condition or mental retardation. The prevalence of DCD has been estimated to be as high as 6% for children aged from 5 to 11 years in America. In addition to motor coordination problems, studies have demonstrated that children with DCD often have an increased risk of emotional and behavioral problems, such as depression, anxiety and attention deficit. In contrast to the rate of emotional and behavioral problems in typically developing children (5% to 12%), that in children with DCD was much higher (43.2 % to 62 %). There have been some studies investigating emotional and behavioral problems in children with DCD. Despite that, some limitations were noted as follows: 1) participants were from a wide range of age (from preschoolers to adolescents) ; 2) only one or two facets of the emotional and behavioral problems in DCD were examined, for example anxiety and depression. Furthermore, no study considered both emotional and behavioral problems simultaneously; 3) no study took into account both personal factors and environmental factors when examining the predictors of emotional and behavioral problems in preschoolers with DCD. In view of the vital importance of early intervention, this study employed the preschoolers with DCD. The aim of this study was threefold, 1) to examine group differences in both emotional and behavioral problems between preschoolers with DCD and typically developing preschoolers (TD), considering both internalizing and externalizing problems simultaneously, 2) to investigate the rate of the emotional and behavioral problems occurred in preschoolers with DCD, 3) to identify the predictors of the behavioral and emotional problems in preschoolers with DCD taking into account both the personal factors (e.g., gender, age) and environmental factors (e.g., birth order, parenting stress ).

Methods: Participants aged between 3 and 5.9 years were recruited from 22 kindergartens in Taiwan and two rehabilitation clinics of two medical centers in Taipei area. Letters describing the purpose and procedure of the study were distributed to 1680 parents of children; 1367 families agreed to participate and completed the Chinese version of the Little Developmental Coordination Disorder Questionnaire Chinese version (LDCDQ-C) to screen motor coordination problems. One hundred and seventy children who scored below the 15th percentile on the LDCDQ-C were further tested with Movement Assessment Battery for Children-2 (MABC-2) to confirm their motor problems. Among them, 86 scored below the 15th percentile on both the LDCDQ-C and MABC-2 were classified as DCD. Fifty six typically developing children (TD) from community samples who scored above the 15th percentile on both the LDCDQ-C and MABC-2 served as controls. Parents of both groups were asked to fill out the Child Behavioral Checklist Chinese version 1.5-5 (CBCL-C/1.5-5), Daily living skills subscale of the Vineland Adaptive Behavior Scale Chinese version (VABS-C) and the Parenting Stress Index Short Form (PSI-SF). Group differences in the CBCL-C/1.5-5 were examined using independent two-sample t test. Furthermore, the percentage of DCD and TD who scored in the clinically significant range on the emotional and behavioral problems was investigated. Multiple linear regression models were fitted to identify the predictors of behavioral and emotional problems as measured by the CBCL-C/1.5-5 in preschooler with DCD. The dependent variables were the CBCL-C/1.5-5 T scores (including internalizing and externalizing scores), the independent variables including personal factors: gender, age, perinatal risk (e.g., anoxia, prolonged or difficult labor, mechanical injuries, and intracranial hemorrhage), level of motor impairment, daily living skills and extrinsic factors: birth order, family socio-economic status, mothers’ age at the birth of the child and parenting stress.

Results: Results showed that preschoolers with DCD had more severe internalizing (t=4.76, p<0.001) and externalizing (t=5.96, p<0.001) problems as measured by the CBCL-C/1.5-5 than TD. Further, in seven narrow-band syndrome scales of the CBCL-C/1.5-5, preschoolers with DCD showed more severe emotional and behavioral problems than TD excepting the Somatic Complaints (t=1.22, p=0.22). As regards the rate of emotional and behavioral problems, more preschoolers with DCD scored in the clinically significant range i.e., 32.6% (DCD) vs. 3.5% (TD) for the total score of CBCL-C/1.5~5; 34.9% (DCD) vs. 10.7% (TD) for the internalizing problems ; 26.7% (DCD) vs. 1.7% (TD) for the externalizing problems. About one half (57 %) of children with DCD had at least one CBCL-C narrow-band syndrome scale scores falling in the clinically significant range, which was much higher than that of typically developing children (12.5%). The highest percentage of clinically significant scores in children with DCD was Withdrawn behavior (38.4%), followed by Attention problems (24.4%) and Emotionally reactive (23.3%). The predictors of the emotional problems in preschooler with DCD were parenting stress and severity of fine motor impairment whereas those of behavioral problems were parenting stress, family SES and gender. The higher parenting stress and severer fine motor impairment, the more emotional problems occurred in children with DCD. The higher parenting stress, the lower family SES, and male gender, the more behavioral problems occurred in children with DCD. The Results of the study indicated that both environmental and personal characteristics factors have impacts on the emotional and behavioral problems of preschooler with DCD.

Conclusions: Results of the study indicated that in addition to motor clumsiness, clinicians have to recognize the need for assessing the emotional and behavioral problems in preschoolers with DCD, especially in withdrawn, attention and emotionally reactive problems. Knowledge of predictors of emotional and behavioral problems helps clinicians and educators to plan intervention and educational programs targeted at these predictors, for examples providing coping strategies or parent support groups to help relieve parents’ stress, providing fine motor skill training for children with DCD. Moreover, in addition to assessment of motor function, it is essential to recognize the need for assessment of emotional and behavioral problems in boys with DCD or in children from families with low SES. By identifying such problems at preschool stage, and proactively helping these children and their parents, they will be able to more actively participate in society and live more productive lives.

並列關鍵字

Developmental Coordination Disorder (DCD) ； emotional and behavioral problems ； parenting stress

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