半側偏癱腦性麻痺孩童發展性忽略測驗之發展

Abstract

背景與目的：半側偏癱腦性麻痺孩童可能會因上肢動作品質不佳而導致使用量顯著低於潛藏能力，此現象被稱為發展性忽略。發展性忽略可能會大幅限制孩童的日常參與，但目前尚未有評估工具足以廣泛評估與了解發展性忽略，包含：欠缺同時使用客觀與主觀量測、欠缺以雙手日常任務評估的工具，以及欠缺動作品質與使用量關係的討論。因此，本研究目的在於：(1) 發展一個能廣泛評估的發展性忽略測驗 (Observatory test of developmental disregard, OTDD)，內容包括：選用適當雙手項目、使用主觀問卷和客觀測量，並比較上肢使用之表現、能力與此二建構間的差異；(2) 檢驗發展性忽略測驗的心理計量特性，包括：評分系統的一致性、收斂及已知族群效度；(3) 初步探討上肢的發展性忽略和動作品質之間的關係。 方法：考慮雙手動作發展以及兒童的日常生活職能，研究者選出19個日常生活雙手項目作為OTDD題庫，採用了觀察測驗 (Observation-based developmental disregard, OBDD)與活動問卷(Questionnaire-based developmental disregard, QBDD)調查做為評估方式，並招募了半側偏癱腦性麻痺孩童和正常發展孩童以驗證其信效度。半側偏癱腦性麻痺孩童之OBDD施測可分為兩階段：自然情境與迫用情境。在自然情境下，孩童以自身慣用之動作模式完成19個項目。孩童於自然情境中未使用雙手操作的項目，將在迫用情境下再次進行施測，此情境之指導語指示了孩童必須使用患側手協助任務進行。施測同時，腦麻孩童的照顧者需填寫QBDD與作為效度校標之問卷，兒童動作日誌 (Pediatric Motor Activity Log-Revised, PMAL-R)。正常發展孩童組，則僅需接受自然情境施測。 結果：本研究招募了16名半側偏癱腦性麻痺孩童與14名正常發展孩童。OBDD和QBDD之內部一致性獲得驗證，其Cronbach’s α皆超過0.9。外部一致性則透過小組討論後，比較施測者間的評分結果之方法驗證。有關效度部分，已知族群效度由兩族群間OBDD-AOU和OBDD-QOM的差異顯著（P <0.05）支持。收斂效度則由OBDD，QBDD和PMAL-R之間之中至高度顯著相關性（P <0.05）支持，目前僅有OBDD-QOM和PMAL-QOM間的相關性未達到顯著相關（P = 0.068）。此外，研究結果顯示，需要接受迫用情境之孩童在OBDD-QOM的得分上顯著低於不需接受迫用情境的孩童（P <0.05），且從迫用情境得到的之使用量分數與OBDD-QOM呈高度負相關（R = -0.928）。 討論：OTDD是一個能廣泛評估發展性忽略的工具並具有良好的心理計量特性。相較於之前的評估工具，OTDD包括了雙手日常任務，動作使用量、動作品質的量化，且以主觀和客觀兩種方式測量。因此，半側偏癱腦麻孩童之患側上肢的使用傾向得以被深入研究。關於發展性忽略和動作品質之間的關係上，兩者的高度相關顯示了動作品質可能對於發展性忽略具有影響性，進一步的研究可以繼續研究兩者關連性，以提供對臨床和研究更深入之建議。 結論：本研究初步證實OTDD之信效度，結果顯示OTDD可作為半側偏癱腦性麻痺孩童患側手使用的評估工具之潛力。未來研究可使用更大的樣本數、選用與日常生活相關的校標工具並簡化OTDD的設計，以便OTDD於日後能更有效地評估發育性忽略的狀況。 關鍵字：發展性忽略，動作能力，動作表現，心理計量特性

Background and Purpose: Children with hemiplegic cerebral palsy (CP) might underuse the affected upper limb to the extent not parallel to the preserved capacity due to the insufficient quality of movement (QOM), and this is called developmental disregard. Development disregard could compromise children’s daily participation. However, there has not been a comprehensive evaluation tool to assess the developmental disregard which assesses the performance compared to the capacity of the amount of use (AOU) of the affected upper limb with proper bimanual daily items in both the subjective and the objective measurements, and no discussion of the impacts of QOM on AOU has been proposed to study the developmental disregard. Therefore, the study aimed to: (1) to develop a tool called the observatory test of the developmental disregard (OTDD) to measure developmental disregard comprehensively including selected proper items, comprising subjective (Questionnaire-based developmental disregard, QBDD) and objective (Observation-based developmental disregard, OBDD) measurements, and evaluating the performance, the capacity of AOU of the affected upper limb and the discrepancy between these two constructs; (2) to examine the psychometric properties of OTDD including the consistency of the scoring system and the convergent and known-group validities; (3) to preliminarily explore the relationship between the developmental disregard and QOM of the affected upper limb. Method: Children with hemiplegic CP and typically developing children were recruited to validate the 19-item OTDD whose items were selected based on the development of the bimanual movement and children’s daily occupations. For those with CP, at least the spontaneous session of OBDD was implemented, and the force-use session was implemented for those items in which they did not use the affected limb to carry out. At the same time, their caregivers were asked to fill in QBDD and the criterion outcome measure, the pediatric motor activity log-revised (PMAL-R). For the typically developing children, they should only take the spontaneous session of OBDD. The results of AOU and QOM of two groups were then analyzed. Results: 16 children with hemiplegic CP and 14 typically developing children were recruited. The internal consistency was ensured by the Cronbach’s α over 0.9 in OBDD and QBDD. The external consistency was ensured by the panel discussion. The known-group validity was supported by the significant differences between two groups in OBDD-AOU and OBDD-QOM (p<0.05). The convergent validity was supported by the significant moderate to high correlation between OBDD, QBDD and PMAL-R (p<0.05) with the exception between OBDD-QOM and PMAL-QOM (p=0.068). The results also showed that the children with developmental disregard who was defined as having accepted the force-use session of the OBDD had lower QOM score those without developmental disregard (p<0.05), and the score derived from the force-use session was negatively and highly correlated with OBDD-QOM (r=-0.928). Discussion: OTDD is a comprehensive tool for the developmental disregard with good psychometric properties. Compared to the previous tools, OTDD includes bimanual daily items, quantification of the motor performance, motor capacity and quality of movement, and both the subjective and the objective measurements; thus, the tendency to use the affected upper limb could be thoroughly studied. As to the relationship between the developmental disregard and QOM, the significant correlation revealed improving QOM could have effects in the developmental disregard. Further studies could be done to provide more implications for the clinic and the research. Conclusion: The study preliminarily validated OTDD, and the result showed the promising use of OTDD in children with hemiplegic CP. In the future, using larger sample size and versatile tools for validation and simplifying the design of OTDD are suggested so that OTDD could more efficiently assess the developmental disregard in children with hemiplegic CP. Keywords: Developmental Disregard, Performance, Capacity, Psychometric Properties