罹患自閉症類群障礙的臺灣幼兒之行為與動作發展

Abstract

自閉症類群障礙(簡稱自閉症)是一種神經發展障礙性疾病，其核心症狀為社交溝通缺損與侷限、重複的固著行為和興趣。過去研究顯示自閉症兒童異常的行為與動作發展問題常在嬰幼兒階段出現，然而過去研究較少使用標準化的發展測驗工具評估自閉症幼兒的動作發展問題，亦無針對臺灣自閉症兒童的相關研究。此外，過去研究發現極低或超低出生體重早產兒較正常足月兒有較多的自閉症狀特質與較高的危險性罹患自閉症，然而過去並無探討足月出生且罹患自閉症之幼兒與極低出生體重早產幼兒的發展差異。因此，本研究之目的為探討臺灣足月自閉症幼兒的動作與行為發展表現，並和同齡之足月正常幼兒與極低出生體重早產幼兒的發展做比較。本研究共招募15位年齡30或36個月大的足月自閉症幼兒、15位正常足月幼兒、與30位極低出生體重早產幼兒。受試兒童接受行為發展與動作功能的評估。行為發展測量包括:(1)父母填寫一歲半至五歲兒童行為檢核表之問卷;(2)使用自動化行為追蹤系統測量幼兒在自由玩耍情境下的行為軌跡與興趣場域;以及(3)父母填寫重複行為量表修訂版之問卷。幼兒的動作發展使用皮巴迪動作發展量表第二版測量多項的動作功能。研究使用曼-惠特尼U檢驗各項發展指標在足月自閉症幼兒、極低出生體重早產幼兒，與正常足月幼兒間的組別差異，並使用簡單線性回歸比較自閉症或極低出生體重且早產的因素之於行為與動作發展問題的效應。研究結果顯示，在一歲半至五歲兒童行為檢核表之問卷結果中，足月自閉症幼兒在其中四種精神疾病導向問題、六種窄帶行為症狀、內顯與外顯問題、及總行為問題的分數均顯著高於正常足月幼兒；相反地，極低出生體重早產幼兒在情感問題、廣泛發展性問題、情緒反應、身體抱怨、退縮、注意力問題及內顯問題的分數，均與正常足月幼兒的分數相當。並且，自動化行為追蹤系統發現，足月自閉症幼兒較正常足月幼兒停留在周邊場域的時間較長、進入父母場域所花的時間較短、以及在轉圈動作時有較高的旋轉角速度；然而，極低出生體重早產幼兒與正常足月幼兒的表現相當。再者，重複行為量表修訂版的問卷結果發現足月自閉症幼兒相較正常足月幼兒，在總分、固著性行為、固定行為(抗拒變化，堅持事物維持原樣)與受限行為(受限的關心範圍、感興趣與活動範圍)的分數均顯著較高；然而，極低出生體重早產幼兒在與正常足月幼兒的分數並無顯著差異。此外，足月自閉症幼兒在皮巴迪動作發展量表第二版的總動作、粗大動作及精細動作分數均顯著低於正常足月兒，並且足月自閉症幼兒有較高比率落於動作極差的等級；然而，極低出生體重早產兒只有在移位分數較正常足月兒低落。此外，研究發現自閉症因素與精神疾病導向問題、外顯問題、總問題分數、與移位動作分數，均比極低出生體重且早產因素有更高的相關性。本篇研究結果顯示，30與36個月的足月自閉症幼兒表現多樣的行為問題與低落的動作功能。雖然極低出生體重合併早產這個因素，會與外顯問題與低落的移位功能有關，其對於行為和動作發展問題的影響低於自閉症。在臨床應用上，本篇研究顯示全面且早期介入自閉症幼兒的行為與動作發展問題是有必要的。

Background and Purposes: Studies have suggested that behavioral and motor developmental problems typically occur in the early childhood of people with autism spectrum disorder (ASD). However, few studies have used standardized developmental assessment instruments for evaluating early motor developmental disorders in toddlers with ASD. Furthermore, very-low-birth-weight preterm (VLBW-PT) toddlers were found to exhibit more autistic traits and a higher risk of ASD than full-term (FT) toddlers. However, developmental differences between FT toddlers with ASD (FT-ASD) and VLBW-PT toddlers have rarely been evaluated. Therefore, the present study investigated the behavioral and motor development of Taiwanese toddlers with ASD and compared the development between FT-ASD, FT typically developing (FT-TD), and VLBW-PT toddlers. Methods: In total, 15 FT-ASD, 15 FT-TD, and 30 VLBW-PT toddlers aged 30 or 36 months were included in this study. All toddlers’ behavioral performances were examined using the Child Behavior Checklist for Ages 1.5–5 (CBCL/1.5–5) and the Repetitive Behavior Scale-Revised (RBS-R). Behavioral trajectory and interests were examined in a free play situation by using the automated behavioral tracking system. Toddlers’ motor functions were examined using the Peabody Developmental Motor Scales, Second Edition (PDMS-2). The Mann–Whitney U test was conducted to examine the differences in each developmental indicator among the groups. For the behavioral or motor indicators for which both FT-ASD and VLBW-PT toddlers differed significantly compared with FT-TD toddlers, a simple linear regression analysis was conducted to determine the effects of ASD versus VLBW and Preterm birth. Results: The results indicated that FT-ASD toddlers achieved significantly higher CBCL/1.5–5 scores than FT-TD toddlers for four Diagnostic and Statistical Manual of Mental Disorders (DSM)-Oriented Scales; six Narrow-band syndromes; and Internalizing, Externalizing, and Total Problems (all p’s < 0.05). By contrast, VLBW-PT toddlers and FT-TD toddlers had comparable scores for Affective and Pervasive Developmental Problems, Emotionally Reactive, Somatic Complaints, Withdrawn, Attention Problems and Internalizing Problems. Furthermore, the behavioral tracking data revealed that FT-ASD toddlers spent significantly longer durations in peripheral areas, had less latency to approach the parent, and had higher absolute angular velocities of repetitive turning movements than FT-TD toddlers (all p’s < 0.05), whereas VLBW-PT and FT-TD toddlers had comparable behavioral tracking results. Moreover, FT-ASD toddlers had higher total RBS-R scores and stereotyped, sameness, and restricted behavior subscales scores than FT-TD toddlers (all p’s < 0.05), whereas VLBW-PT and FT-TD toddlers had comparable RBS-R scales scores. In addition, the motor function assessment results revealed that FT-ASD toddlers achieved significantly lower motor scores and a higher proportion of poor classification in the Total, Gross, and Fine Motor Scales of the PDMS-2 than FT-TD toddlers (all p’s < 0.05), whereas VLBW-PT and FT-TD toddlers had comparable motor scores, except for locomotion scores, which were lower in VLBW-PT toddlers. The higher effects of ASD on several behavioral and motor indicators were associated with higher scores for the DSM-Oriented Scales (β = 1.8 – 2.5), Externalizing (β = 6.8), and Total Problems (β = 24.8); and lower locomotion scores (β = -1.7) compared with the effects of VLBW and Preterm birth (all p’s < 0.05). The present findings revealed that FT-ASD toddlers exhibited high degrees of various behavioral problems and poor motor functions at the ages of 30 and 36 months. Although VLBW and preterm birth may be associated with externalizing problems and poor locomotion skills, their effects on behavioral or motor performances were milder than those of ASD. The present findings suggest that comprehensive interventions focused on multiple behavioral and motor developmental domains are necessary for toddlers with ASD.