以國際功能、失能與健康分類系統-兒童青少年版理論架構探討學前自閉症兒童母親之親職壓力預測因子

The Predictors of Parenting Stress in Mothers of Preschoolers with Autism Spectrum Disorders based on the perspective of the International Classification of Functioning, Disability and Health for Children and Youth Framework

邱資皇(Tzu-Huang Chiou)

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.2012.02204

摘要

研究背景：自閉症障礙類群(Autistic Spectrum Disorders, ASD)的核心症狀為溝通與社交方面質的異常、重複且侷限的興趣與行為。除上述核心症狀外，此類兒童也同時具有感覺處理異常、智能不足、行為問題、無法執行自我照顧活動或參與家庭活動。照顧自閉症障礙類群對兒童，父母不僅必須面對症狀所帶來的困擾，更面臨長期照顧而累積的壓力。由於自閉症障礙類群兒童功能及障礙的複雜性，使用一個理論架構幫助我們完整釐清影響自閉症障礙類群兒童母親之親職壓力的相關因子是極為重要的。世界衛生組織(World Health Organization, WHO)於2007年倡導使用「國際功能、失能與健康分類系統-兒童青少年版」(International Classification of Functioning, Disability and Health for Children and Youth, ICF-CY)的理論架構及專門術語來描述兒童健康及健康相關的狀態。ICF-CY改變以往對於健康的定義與概念，由疾病的焦點轉移到功能的重視，並考量環境與個人因素的影響程度。目前探討影響自閉症障礙類群兒童母親之親職壓力相關因子的研究並未全面地探討健康狀況、身體功能及構造、活動與參與、個人及環境因素，多數僅探討其中兩至三個面向的相關因素。此外，之前研究樣本診斷的異質性高，樣本的年齡範圍較廣，由嬰幼兒至青少年甚至成人。對於學齡前自閉症障礙類群兒童的研究樣本數較少，有的兒童發展程度偏低且多數具有中度到極重度的智力不足，影響到研究結果的應用性。
研究目的：本研究的目的將依據ICF-CY架構，探討影響學齡前自閉症障礙類群兒童母親之親職壓力的影響因子，並了解學齡前ASD兒童母親之親職壓力的預測因子。
研究方法：招募來自全台灣的幼稚園、兒童復健科診所、發展中心、醫院之復健科或兒童精神科的學齡前自閉症障礙類群兒童。納入條件包括：(1)兒童被兒童精神科醫師依據DSM-IV-TR診斷為自閉症(autistic disorder)、亞斯伯格症(Asperger disorder)或待分類的廣泛性發展障礙(Pervasive Developmental Disorder Not Otherwise Specified, PDD-NOS)；兒童年齡為3歲0個月至5歲11個月31天；(3)兒童的母親同意兒童參與此研究並簽署同意書。排除條件包括：(1)兒童有感覺功能的障礙，如視障或聽障，或兒童有嚴重的動作障礙會影響接受施測；(2)兒童的母親無法以中文或台語溝通。符合收案標準且母親簽署同意書的兒童接受研究者一對一施測中文兒童心理教育量表-第三版(Chinese Psychoeducational Profile-third edition)。接著兒童與研究人員或手足進行15-20分鐘的自由遊戲，另一名研究者觀察兒童評估及自由遊戲時的表現並使用兒童自閉症評量表(Childhood Autism Rating Scale)計分。同時，第三位研究者將使用中文版文蘭適應行為量表(Vineland Adaptive Behavior Scale)訪談兒童之母親。所有評估及訪談結束後，請母親填寫問卷，包括基本資料表、兒童行為調查問卷(Child Behavior Checklist/1.5-5, ABAC/1.5-5)、中文版兒童氣質量表(Behavior Style Questionnaire-Chinese, BSQ-C)、感覺處理能力剖析表-簡短版(Short Sensory Profile, SSP)、正向情緒指數(Positive Affect Index)、親職壓力表-中文簡短版(Parenting Stress Index-Chinese Short Form, PSI-CSF)，請母親於兩週後將問卷寄回。
資料分析：針對兒童健康狀態、身體功能及構造、活動及參與、個人、環境因素等變項進行描述性統計及皮爾森相關(Pearson Product Moment Correlation)分析。並以多元線性迴歸模式(Multiple liner regression models)探討學齡前自閉症障礙類群兒童母親之親職壓力的重要預測因子。依變項包括PSI-CSF分數，獨立變項包括所觀察到兒童健康狀態、身體功能及構造、活動及參與、個人及環境因素等變項。
結果：共有89位三至五歲的自閉症障礙類群兒童參與本研究。皮爾森相關分析顯示自閉症障礙類群兒童母親之親職壓力與孩子的症狀嚴重度、行為情緒問題呈顯著正相關，與母親的正向情緒、孩子氣質的規律性、感覺處理功能、認知程度、表達與溝通能力、日常生活技巧或社會化程度呈顯著負相關。自閉症障礙類群兒童母親之親職壓力之顯著預測因子為孩子的內化問題、症狀嚴重度、規律性與母親的正向情緒。
結論：本研究為第一個採用「國際功能失能與健康分類系統-兒童青少年版」架構調查學齡前自閉症障礙類群兒童母親之親職壓力的研究。研究結果有助於專業人員瞭解影響學齡前自閉症障礙類群兒童母親之親職壓力的相關及預測因子，以訂定有效的治療與支持計劃，教導母親應對策略及尋求社會支持以舒緩壓力及協助心理調適，並可作為政府制定施政方針的參考。

關鍵字

自閉症障礙類群 ； 親職壓力 ； 國際功能失能與健康分類系統-兒童青少年版 ； 學齡前兒童 ； 預測因子

並列摘要

Background: Autism Spectrum Disorders is characterized by qualitative impairments in communication and social interaction, along with restricted, repetitive and stereotyped interests. Besides the core symptoms, children with ASD also have various associated deficits such as atypical sensory processing, impaired intellectual function, behavior problems, and difficulty in self-care skills or participation in family activities, which may have greatly affected parenting stress. Because of the complex nature of problems in children with ASD, employing a holistic framework to identify the factors influencing maternal stress is crucial. The World Health Organization advocates a uniform framework and terminology, the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY), for the description of health and health-related states in children and youth population. ICF-CY has changed the previous concept and definition about health. It not only focuses on disability but also on function, and considers the interaction between disease, function, environmental and personal factors. To date, studies examining the predictors of maternal stress in children with ASD only included factors from two or three specific dimensions without taking into account the possible factors from all the dimensions of ICF-CY simultaneously. Moreover, previous studies employed participants with a wide age range (e.g., from preschoolers to adults) such that the results may not be applicable to children in a specific age range, such as preschoolers. Furthermore, using the ICF-CY framework to investigate the predictors of maternal stress in children with ASD is essential for a comprehensive understanding of factors associated with maternal parenting stress.
Purposes: The purpose of this study was to investigate the factors related to the maternal parenting stress in preschoolers with ASD using the ICF-CY framework by considering the potential factors from all dimensions of the ICF-CY.
Methods: Preschoolers with ASD were recruited from developmental centers, pediatric rehabilitation clinics, and child psychiatry and rehabilitation departments of general hospitals in Taiwan. The inclusion criteria included (1) preschool children were diagnosed with autistic disorder, Asperger’s disorder, or PDD-NOS by child psychiatrists based on criteria of the DSM-IV-TR, and (2) children’s mother agreed to participate and give the informed consent. The exclusion criteria were (1) children with sensory limitations such as blindness, deafness, and severe motor limitations which hindered adequate testing, and (2) children’s mother unable to communicate in Mandarin or Taiwanese. The child with informed consent received a one-to-one assessment using the Chinese Psychoeducational Profile-third edition (CPEP-3) by a researcher. Another researcher rated the child’s behaviors using the Childhood Autism Rating Scale. Meanwhile, the child’s mother was interviewed by a third researcher using the Vineland Adaptive Behavior Scale-Chinese classroom edition. After completion of the CPEP-3, a package of questionnaires including a basic information questionnaire, the Behavior Style Questionnaire-Chinese version, the Child Behavior Checklist for Ages 1.5-5 - Chinese version, the Short Sensory Profile-Chinese version, Positive Affect Index, and the Parenting Stress Index-Chinese Short Form were given to the mother.
Statistical analysis: Descriptive analysis and Pearson Product Moment Correlation analysis were conducted for the observed variables in ICF-CY framework. Multiple linear regression models were fitted to identify the significant factors of parenting stress in mothers of preschooler with ASD.
Results: Eighty-nine preschoolers with ASD aged from 3 to 5 years old were recruited. Pearson correlation demonstrated that maternal parenting stress was significantly positively correlated with the severity of symptoms, emotional and behavior problems. But maternal parenting stress was significantly and negatively correlated with mother’s positive affect, child’s rhythmicity, sensory processing, cognitive, expressive language and communication, daily living skills, and socialization. The strongest predictors of parenting stress in mothers of preschoolers with ASD were child’s internalizing problems, high rhythmicity, the severity of symptoms, and mother’s positive affect.
Conclusion: This is the first study investigating the parenting stress in mothers of preschoolers with ASD adopting the conceptual framework of the ICF-CY. Findings suggest that early diagnosis and interventions, coping strategies and social support should be provided to mothers of preschooler with ASD to assist their stress relief and psychological adjustment.

並列關鍵字

Autism spectrum disorders ； parenting stress ； ICF-CY ； preschooler ； predictor

參考文獻

World Health Organization. (2001). Internal Classification of Functioning, Disability and Health: ICF. Geneva: WHO.

Chen, Y. C., Huang, H. L., & Chao, C. C. (2009). Child Behavior Checklist for Ages 1.5-5-Chinese version. Taipei: Psychological Publishing.

Schopler, E., Lansing, M. D., Reichler, R. J., & Marcus, L. M. (2005). Examiner’s manual of Psycheducational Profile (3rd ed.). Austin, Texas: Pro-ed Incorporation.

Abidin, R. R. (1992). The determinants of parenting behavior. Journal of Clinical Child Psychology, 21, 407-412.

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorder: DSM-IV-TR (fouth, test revision ed.). Washington, DC: American Psychiatric Association.